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Authority Cited. Chapter 6.7,Health*and Safety Code Chapter 16,Division 3. TFtle#—ahjornia C,oae ojKeSuiarrons � tY and servicing of moaitoring equipment.-NS quipment A separate certification or report must be "This form must be used to document testing performs the work. A copy of this form Must be provided to aced for each monitoring system control panel by the technician whoopperf to UST systems the tank system owner/operator. The ownerloperatDr must submit a coy of this form to the local agency )� g within 30 days of test date. A. General Information 7 Bldg.No.:______ Facility Name: /yL' % Zip- 5-2 0 q C� o - Site Address: � city: Contact Phone No.: 7 Facility Contact Person: Date of Testing/Sarvicmg: Make/Model of Monitoring System: B. Inventory of Equipment TeSted/Certiftetl i. Check the appropriate taxes to indicate specific equipment inspected/se"iced: r, Tank ID: G ) k Tank Gauging Probe: Model: 6 In-Tank Gauging Probe. Model: �° II alar Space or Vault Sensor. Model: ` ti 1$Annular Space or Vault Sensor. Model: 11 p, ing Sump/Trench Sensor(s). Model: it Piping Sump/Trench Sensor(s). Model: 0. ❑ ill Sump Sensor(s). Model- 1h Fill Sump Sensor(s). Model: d- ®Mechanical Line Leak Detector. Model: -a (� Mechanical Line Leak Detector. Model: / ❑ Electronic Line Leak Detector. Model: j� ❑ lectronic Line Leak Detector. Model: - VTank Overfill/H�sor. Model:�P�y°/ SrJ _r�/ Tank Overfill/High-Level Sensor. Model: U /iy l' r (j k ❑ Other(specify equipment type and model in Section E on Page 2. fl ❑ Other( ify equipment type and model in Section E on Page 2}. r Tank ID: Tank ID: O In Tank Gauging Probe. Model: 6 In-Tank Gau Probe. Madel: � �Z3 Annular Space or Vault Sensor. Model: i 81 Annular Space or Vault Sensor. Model: ❑ p i O 1 ❑ Piping Sump/Trench Sensor(s). Model: !!Ib Piping Sump/Trench Sensor(s). Model: !.; ❑ Fill Sump Sensor(s). Model: � ❑ Fill Sump Sensor(s). Model: ; �— oZcy- ❑ Mechanical Line Leak Detector. Model: lb Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: �1 ❑ Electronic Line Leak Detector. Model: f41 Tank Overfill/Iii - or. Model:y e.V �S ❑ T �'e1 /High-Level Sensor. Model: i� ®'Other(specify equipment and model in Section E on Page 2). ❑ Other(specify equipment type.and model in Section fi on Page 2}. �I I)is r ID: Disp r ID: 3 O Containment Sen or(s). Model: I� ❑ enser Containment ensor(s). Model: jj Vaiv s S Valve(s). I j; e(). �} IKDi�spenser Containment Float(s)and Chain(s). Dispeeser Containment Floats)and Chain(s). ! ! ii Dispenser ID: n Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: a ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). R ❑ Shear Valve(s)_ 1 0 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). 1 Dispenser ID: Dispenser ID: ' jl ❑ Dispenser Containment Sensor(s). Model; ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ; ❑ Shear Valve(s). ! s ! ❑Dispenser Containment Float(s)and Chain(s). ❑ 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, manuf rens' checklists) necessary to verify that this information is correct and a PIot Plan showing the layout of monitoring equipm For any equipment Te of generating such reports,I have also attached a copy of the report;(check all that apply• to t-up arm history report Technician Name(print):_Tom Corcoran Signature: Certification No.: C�0 7 S 3 1 License.No.: d 146 Z Testing Company Name: Triangle Environmental,Inc. Phone No.:(818)840 7020 S/�� Site Address: Date of Testing/Servicing: b Page 1 of 3 03101