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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 tank days of test date. 30 A. General Information Facility Name: F6`11 Bldg.No.: Site Address: 6/G� va N/ate � City: /IJ/� Zip: Facility Contact Person: N1 5 4/--- Contact Phone No.:( ) Make/Model of Monitoring System: --T-�.1 J Date of Testing/Servicing: .-/AS=/ 0>> B. Inventory of Equipment Tested/Certified Ch the appropriate boxes to indicates ecifc a ui ment ins ected/serviced: T ID: Tk ID: F nk Gauging Probe. Model: *I'd - l of Tank Gauging Probe. Model:ular Space or Vault Sensor. Model: �/U nnnular Space or Vault Sensor. Model: ng Sump/Trench Sensor(s). Model: o? d U P' ing Sump/Trench Sensor(s). Model: o U Sump Sensor(s). Model: ❑ ill Sump Sensor(s). Model: hanical Line Leak Detector. Model: y �Z�7s�— Mechanical Line Leak Detector. Model: U electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/Hig"a J-&:eWy@n or. Model: eCAr e4 r )t A a ❑ Tank Overfill/H' �, v etsoc Model:_ P �/SL ❑ Other(specify ui ment type and model in Section E on Page 2). ❑ Other(specify ui ment type and model in Section E on Pae 2). Tjink ID: / Tank ID: yZink Gauging Probe. Model: A R-/ ❑ In-Tank Gauging Probe. Model: pular Space or Vault Sensor. Model: ` 7 ❑ Annular Space or Vault Sensor. Model: 23 Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑�Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: M hanical Line Leak Detector. Model: �1 ❑ Mechanical Line Leak Detector. Model: U �rfectronic Line Leak Detector. Model: L3 Electronic Line Leak Detector, Model: Tank Overfill/HigbztZXELSa%6w. Model:t-D lot,/ y 1 S C., ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(seEify equipment type and model in Section E on Page 2). ❑ Other(s cif Squiement t odel in Section E on Pae 2). i gispenser ; Dispen ID: er Containment ensor(s). Model: Cl -ser Containment Sensor(s). Model: alve(s). ar Valve(s). Containment Float(s)and Chain(s). �Iispenscr 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 Float(s)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). ❑Dis enser 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. ` nufacturers' checklists) necessa"(f verify that�us information is correct and a Plot Plan showing the layout of monitoring equ' ment. For any equipm6nt capable oCgenerating sucl reports,I have also attached a copy of the report;(check alllhat apply): ystem set-up 0 Alarltt ttisttSiy report Technician Name(print): =< — Signature: �T Certification No.: TRIANGLE ENVIRONMENTAL, INC. '. License.No.: >.= Testing Company 2 Phone No.: Site Address: - Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification