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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at U91/www.waterboards.ca.clov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited., Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. Aseparate certification or report must be prepared for each monitoring system control panel by the technician who performs the ;work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information , . I1 YY� .p Facility Name: 1 1 1 1(� I CICAi n1 1 I I' V,J M" �/ Bldg. No.: - Site p{� Site Address:2�' lN�}Aeoi 1 Amy city: _y�u:.t TAO Zip: 62 Facility Contact Person: I& Contact Phone No.: (01) -t8 ' U 2 Make/Model of Monitoring System: FICI:[ Date of Testing/Servicing: S. Inventory of Equipment Tested/Certified Check t a appropriate boxes to indicatespecific equipment insacted/service d If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment Identified in this document was Inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is Information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ❑ System set-up ❑ Alarmmmjaistoty rep0A , i Technician Name (print): 4 _111b 444 A,14Z9 Signature: -4�,4 Certification No.: _ Testing Company Name: Testing Company Addret License. of Testing/Servicing: Monitoring System Certification Page 1 of 4 12107 2/21/07 . Tank ID: Tank lD: ❑ In -Tank Gauging Probe. Annular Space Vault Sensor. Model: ❑ In -Tank GZ Probe. Model: .01 or ❑ Piping Sump /Trench Sensor(s). Model:Ey Model: Annular Space or Vault Sensor. Model: ❑ Fill Sump Sensor(s). -a Model:ill V Piping Sump / Trench Sensor(s). Model: t.a X Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. Model: vT•T, — Sump Sensor(s), mechanical Line Leak Detector. Model: Model: f Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill /High -Level Sensor. Model: Others ci a ui mant a and model in Section E on Pae 2 . Cl Other(specify a ui ment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: —El Piping Sump /Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). _ Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 11Electronic Line Leak Detector. Model: 11 Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: - ❑ Tank Overfill / High-LevelSensor. Model: 11 Other s eci equipment type and model in Section E on Pa e 2). ❑ Other s ecif a ui ment !y2e and model in Section E on Pae 2). Dispenser to: / - [ Dispenser ID: ❑ Dispenser Containment Sensor(s). Shear Valve(s). Model: ❑ Dispenser Containment Senors). Model: /r / Shear Valve(s). Dispenser Containment Floats and Chains . Z Dispenser Containment Floats and Chain(s). Dispenser ID: DlspenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Floallsl and Chain(s)., Dispenser ID: Dispenser lD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dise2nser Containment Floats and Chains ❑ Dis enser Containment Floats and Chain(s). If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment Identified in this document was Inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is Information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ❑ System set-up ❑ Alarmmmjaistoty rep0A , i Technician Name (print): 4 _111b 444 A,14Z9 Signature: -4�,4 Certification No.: _ Testing Company Name: Testing Company Addret License. of Testing/Servicing: Monitoring System Certification Page 1 of 4 12107 2/21/07