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02/18/2004 15:21 40B97101tp SSS INC 0 PAGE 02 MONITORING SYSTEM CERTIFICATION For Use#yAll Jurisdictions Nlilhin the Stare ol'Culifornia 4;�thriritt° Cited: Chapter 0,7, Pleulth and SaJOy Code. Chapter It, Division 3, Title 23, Culifornica Cod(a Regulations This forin must be used to document testing; and servicing of monitoring equipment. A separate certification or rWort mgt,be prepared for each monitoring.gymcm control panel by the technician who performs the work. A copy of this form must be provided to the tank sysmm owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systoms within 30 slays of test date, A. Coneral Wormation Facility Narnc: / Bldg,No.: fiats a�triracs:. 7�rli ac t*Qre�t. r - '_r city: _,-,, TrseeZip: Facility Contact Person: Contact'Phone No-: { Make/Modcl of Monitoring Systpm; VC. L SC Date of Testing/Servicing: l 2 9/f B. Inventory of Equipment Tested/Certified CIJULh thl Applo viatt boxos to indicaic+ eci{c L ui m t Irt6 c,"zd/9crYic0d: FAnnular Tank ID ging Probe. Model: ❑ In-Tank Gauging Probe. Model: cc or Vauh Sensor. Model- ❑ Annular Space or Vault Sensor. Model: /Trench Sensor(s), Model, ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Seasons]. Model: ❑ Fill Sump Scnsor(s), Model: ❑ Mechanical Line Leak Detector- Model ❑ Mechanical Line Lcak Detector. Model: - ❑ Electronic Line Leak Detector. Model- ❑ Electronic Line Leak)detector. Model- Z) Tank Overfill 11iiph-a-P-1 firmer Mnrlr.l: ❑ Tank Overfill I High-Level Sensor. Model: ❑ otliet is eclfv equipment t and model in Section 5 on Page 2). ❑ Other(specify equipment t e and model in Section E on PaLe 2). I Tank ID: 'Tank ID. 0 In-Tank Gagging Prubr. Mutic;. D Iii-Tank Gauging Probe- Modcl; ID Annular Space or Vault Sensor- Model: I❑ Annular Space or Vault Sensor. Model: - ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump 1 Trench Scnsor(s), Model: p t=ill Sump Scnsor(s). Model: ❑ Fill Sump Scnsor(s), Model: '3 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Linc Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: I 1.1 Tank Overfill/High-Level Sensor. Model: _ Q lank Overfill/rligh-Level Sensor. Model: ❑ Other(specify a tui ment t c and model in Section E or.Page 2). ❑ Other(specify ui mcnt c and model in Section E oonPug 2). Dispenser Containment Scnsor(s). Madel: ❑ I)ispenser Containment Sensor(s). Mvdel: 6 0 Shear ValVe(s). q Shear Valve(s). ❑ D;, enser Conminmen:Float(s)and Chain(s). II I7is enser Containment Float(s)and Chain(s). Dispenser(ID, Dispenser ID: Dispenser Containmcnt Sensor(S), Model: ❑ Dispenser Containment Sensor(s). Model: i 'J Shear Valve(s). ❑ Shur Valvels). ❑ Dis cnscr Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). I]ispenser ID: Dicpenser ID: ❑ Dispenser Containment Sens0s). Model: I3 Dispenser Containment Sensor(s). Model: D Shear Valve(s I. Q Shear Valve(s). ❑t is wnc�r C,nor tinmPnt Fln,;iW and C'htiin(ti), ❑ Dispenser Containment Float(s)and Chain(sl. •[f the facie its'contains more tanks or dispensers.copy this fomt. Include information for every tank and dispenser at the facility, C. Certification - I certify that the equipment identified its this dortiment wnc in.4pertedAerviewl in accordance with the manufacturers' guidelines. Attached to this Certifeution is information (e.g. manufacturers' checklists) necessary to verity, that this information is correct and a Piot Plan showing the iavout of monitoring equipment. For any egttipment capable of generating such reports.i havgc ulsu auuclied it UUpy Of 111t:t eNor t, ❑ System set-up ❑ Alarm history report Technician Name (print): qtr is !+?��r.�tt��. _._._ Signarure: Ccniilcazioii hV-: ± L / LtGcnsc.No.: TesunF Company Mame;_ �- — __ Phone NoA qQ r Site Address, 7 7/4$ 54&z-, v--, C cif Date ot"Yesting/Servicing:_L171 l o Pine 1 uta 03101 Mouitoring System Certification