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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 Informationp _/ t/� Bldg.No.: Facility Name: St SiteAddress:�� Wit. City: '7%)Cke_t2r1 Zip: Facility Contact Person: mak 0--, Contact Phone No.: ( ) Make/Model of Monitoring System: Ie .l&r �Zo0k -M&`0�2 Date of Testing/Servicing: —4 /—Z-46� B. Inventory of Equipment Tested/Certified Check the ne2rapriate boxes to indicatespecific equipment inspected/serviced: Tank ID: Tank ID: 0 In-Tank Gauging Probe. Model: - 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 0 Annular Spars or Vault Sensor. Model: O Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment tv a and model in Section E on Pace 2). O Other(specify equipment tv a and model in Section E on Page 2). Tank ID: Tank ID: Cl In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(§). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment t e and model in Section E on Pace 2). 0 Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: S - Dispenser ID: 113-11" AF Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). ModelT144,fco—` fLI 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dm nsr Containment Float(s)and Chain(s). Dispenser ID: l-I'11?s _ Dispenser ID: ` ff Dispenser Containment Sensor(s). Moder � �X21 - �(Dispenser Containment Sensor(s). ModcI7T1C 45W-_5Z 0 Shear Valve(s). ,0 Shear Valve(s). 0 Dispenser Containment Floats)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor($). Model: 0 Shear Valve(s). 0 ShearValve(s). DDis enser Containment Float(s)and Chain(s). 0 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 equipment. For any equipment capable of generatin c re h e Iso attached a copy of the report;(check all that apply): ' 11 System set-up 0 Alarm history report Technician Name(print): •mni Ebni-Ann Signature: Certification No.: cj(Q'�-{p�- � License.No.: Testing Company Name: Scott Co. Of California Phone No.:( _� R95-9448 v 4sES Site Address: Date of Testing/Servicing:A 24alm Page 1 of 3 03/01 Monitoring System Certification