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Monitoring System Certification Page 1 of 4 r� Appendix VI MONITORING SYSTEM CERTIFICATION JU� For Use By All Jurisdictions Within the State of California 2009 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code, .o Regulations >ti I/,�ti / H cCOV/V This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for I 'NetVT each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system i 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 �-- f N�mp. Bldg. NO.: / }, Site 0 / ir— e f—t0C►Gl� City: /'I .0— Zip: AddSite Pac Facility Contact Parsrtrc Contact Phone No.: GL 01 Make/Model of Monitoring System: �% T- /` S _-z, es -C7 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicatespecific equipment inspected/serviced: Tank ID: V % Tank ID: 4 In -Tank Gauging Probe. Model: 241 a!3 % ❑ In -Tank Gauging Probe. Model: 1' Annular Space or Vault Sensor. Model: '�j� i� ❑ Annular Space or Vault Sensor. Model: IS Piping Sump / Trench Sensor(s). Model: o _0 g ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: .1 ( V ❑ 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 (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: Z) 1.4 P Tank ID: XIn -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: , -aaJ t %t n ❑ 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). Model: Mechanical Line Leak Detector. Model: cj n/ oc ❑ 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 (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: / �: ;I— Dispenser ID: 6y-1 4 ❑ Dispenser Containment Sensor(s). Model: vZQ `[� ❑ Dispenser Containment Sensor(s). Model: rrZ� ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3 �-!% Dispenser ID: " ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: .5, ❑ 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 ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(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. 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 generating such reports, 1 have also attached a copy of the report; (check all that apply): ❑ System set-up ❑ Alarm history report — - Technician Name (print): Lyle D. Nimmo Signature:G6G �_ 0 Certification No.: 0605 License No: 1143 Testing Company Name: AFFORDA-TEST Phone No. 209 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: Monitoring System Certification Page 1 of 4