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a MONITORING SYSTEM CERTIFICATION Authority Far Use Ry All Jurisdictions Within the State of California ty 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.Aseoarate certification or reoort u r hP f r each Minoring ui anel 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: � Site Address: 6/70 C, Bldg.No.: City: Zip: Facility Contac[Person: Contact Phone No.:(_) Make/Model of Monitoring System: Date of Testing/Servicing: _�CJ_5iJQ2 B. Inventory of Equipment Tested/Certified Cheek the appeopriate boxes to indicatespecific Nuipment ins serviced: Tank ID: - Tank ID: In-Tank Gauging Probe. Model: *,4-1 in-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: O Annular Space or Vault Sensor. Model:4R Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: 70 ❑ Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s). Model: Techanical Line Leak Detector. Model: Odechanical 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: O Other(specify ui t type and model in Section E on Pae 2). ❑ Other(specify equipment type and model in Section E on Pate 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Q 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). Madel: ❑ Mechanical line Leak Detector. Model: ❑ 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(spwify equipment type and model in Section E on PaRe 2). O Other(specify equipment type and model in Section E on Page 2)_ Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensur(s). Model: ❑ Dispenser Containment Semor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: f] Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ ShearValve(s). UDispenser Containment Floats and Chain(s). ❑ Dispenser 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 generator reports,I have also attached a copy of the report• check all that apply): ❑System set-up ❑ ory repo Technician Name(print); o/LGe1L.a^� Signature: CertificationNo.: TRIANGLE ENVIRONMENTAL, INCdd-/Sli ense.No.: ort -/6." ! Testing Company _ - Phone No.: Site Address: CCCCCCUUUUUU 111llitttttt r Date of Testing/Servicing: /_�YJA3 Page 1 of 3 03/01 Monitoring System Certification FAILED