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MONI1-4dRING SYSTEM CERTIFI, ATION For Use By All Jurisdictions Within the State of California Authority CIA. 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 retort 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 Facility Name: - Bldg. p: /\ Site Address: � E 1t3 e t�� C ��S `�r City: Zip: Facility Contact Person: ) Contact Phone No.: t —03 Servn Make/Model of Monitoring System: Date of Testin� icig' B. Inventory of Equipment Tested/Cel r ed Check the appropriate boxes to indicate specifle equipment ins eeted/serviced: Tank ID: Tank ID: ❑ In-Tank Gauging be. Model: U in-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model:_7 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). 0 Mechanical Line Leak Detector. Model E U Mechanical Line Leak D I. ❑ Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Model: ❑ Tank Overfill/Bigh-Level Sensor. Model: U Tank Overfill/High-Level Se 1:�p ❑ Others equipment and model in Section E on Page 2).. 13 other s i ui ment id'Secnon E on—Page 2). Tank ID: Tank ID: —div v inv ❑ In-Tank Gauging Pro e. Model: — ❑ In-Tank Gauging Probe. �FRMI d a}r — • Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sen r ff�� 13 Piping Sump/Trench Sensor(s). Model: [3 Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model:�`� 211 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 11 Tank Overfill/High-Level Sensor. Model: 17 Other(ML, ui men[=and model in Section E on Pa a 2). ❑ Others ui men[=and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Contunment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). O Shear Valve(s). 's user Containment Float(s)and Chains . ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Con omen Sensor(s). Model: U Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). )ZIC"spenser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Q Dispenser Containment Sensor(s). Model: 13 Dispenser Containment Sensor(s). Model: O Shear Valve(s). U Shear Valve(s). UDispenser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chains . -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 ement callable of ge crating such reports,I have also attached a copy of eport;(check all that apt(I qui*System set-up larm h* ry •e Technician Name(print). lli�� 1�\\N Ne.� Signature: Certification No.: C License.No.: Testing Company Name: Phone NoA s&3 Site Address:�� P-,VN' — � Date of Testing/Servicing:__LA_j_r_,,f_ Page 1 of 3 03/01 Monitoring System Certification