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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.A separate 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 � f Facility Name: ��T� Bldg.No.: Site Address: yiS j:j" 'e / City:�QC/ t', Zip: Facility Contact Person: r Contact Phone No.: ( ) Make/Model of Monitoring System: _ 1�G Rr �t ' � Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check theap2repriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: Tank ID: • In-Tank Gauging Probe. Model: - ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Model: • Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment tv a and model in Section E on Pace 2). ❑ Other(specify equipment tv a 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: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Cl Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecifv a ui ment type and model in Section E on Page 2). ❑ Other(s ecifV equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: Dispenser Conta nment Sensor(s). Model: /r y:Z gel Dispenser Containment Sensor(s). Model: Shear Valve(s). L rehear Valve(s). - O Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Floats)and Chain(s). Dispenser ID: •- Dispenser ID: - 91 Dispenser Containment Sensor(s). Model: �f/3�s0"?t."ltr ❑ Dispenser Containment Sensor(s).. Model: IN Shear Val ve(s). ❑ Shear Valve(s). ❑ Dispense I r Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). (J Shearvalve(s). T ❑Dis enser Containment Float(s)and Chain(s). CI Dispenser Containment Float(s)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 pment. For any eq ur ment capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up Alarm history report Technician Name(print): JOt -hnC=ant Signature:/ Certification No.: z(/oma � 4 License.No.: 1 RddR(1 Testing Company Name: Scott Co of Cg1 i fnrni a Phone No.:(-510_) R9S-7774 x zR5 Site Address: Date of Testing/Servicing:_J_/_ Page 1 of 3 03/01 Monitoring System Certification