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MONI'IT`-UNG SYSTEM CERTIEIC" TION For By All Jm•ist ictions II'ithin the.Stale of•Califoi Authority C'itecl: Chapter G.7, Health and Sqf( ,ty Cocke; Chapter 16, Division 3/iewor�k. Title 23, California C:o(le of Re ntlations This fon must be used to document testing ati--seTvki ig of monitoring eqseparate certification or report i ist be re ared for ch monitorings stem control pandl by the technician who perforA copy of this form must be vided to the tank system w t•/operator. Tile.owner/oplerator must subhlit a copy of the local agency regulating 'ST systems within 30 days of to date. •� A. General Infor tion Facility Name: Bid .No.: Site Address: ;,"I Zip: Facility Contact Person: Contact Phone No.:/1ll�S_e_r_ViclIlg:) Make/Model of Monitoring System: ''Date of T s B. Inventory of Equipment Teste \Certified Check theappropriate boxes to indicates ecifie a ui ?n apt ins ected/serviced: Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging`Probe. Model: v ❑ Annular Space or Vault Sen r. Model: ❑ Annular Spa eor Vault Sensor. Model: ❑ Piping Sump/Trench Sens r(s). Model: ❑ Piping Sur /Trench Sensor Model: ❑ `S mp Sensor(s), Model: ❑ Fill Swnensor(s). Model: 0 Mechan I Line Leak D®ector. Model: ❑ Mechuinical Line Leak Detector. o`del: ❑ Electronic line Leak Dector. Model: N\Other Eleronic Line Leak Detector. Mod�ill_ ❑ Tank Overfil High-Level Sensor. Model: 'I"ank Overfill/High-Level Sensor. Mod ❑ Other(specify e``�q.ui f>Tient type and model in Section E on Page 2). (s ecif a ui meat t e and modelectionE on Page 2). Tank ID: X TanWl): ❑ In-Tank Gaugin�,Pro'be. Model: ❑ 1n-T�i,k Gauging Probe. Model ❑ Annular Space or Vain ensor. Model: ❑ Annular ace or Vault Sensor. 'Model: ❑ Piping Sump jvt rench Serisor(s). Model: �y ❑ Piping Sun /Trench Sensors) Model: ., ❑ Fill Sump Sdnsor(s). t a. Model: ❑ Fill Sump Sen �r(s). Model: �v ❑ Mechanicals Line Leak Detector. Model: �`� ❑ Mechanical Line eak Detec(or. Model: `o ❑ Electronic Line Leak Detector.%, Model: ❑ Electronic Line Lea Detector. Model: ❑ Tank OOverfill/High-Level Sensor. Model: �° ❑ Tank Overfill/High- vel Sensor. Model•. ❑ Other(s)ecify equipment type and model in Section E on Page 2). ❑ Other(specify a ui mei type and model in Section E on Pa Disppenser ID: Dispen er ID: El Dispenser Containment Sensor(s). Mode., ❑ D' penser Containment Sens s). Model: ❑ Shear Valve(s). ,a El hear Valve(s). ❑ Dispenser Containment Float(s)and,Chain(s). Dienser Containment Floats)an Chain(s). s Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model "" ❑ �4spenser Containment Sensor(s). Model: ❑ Shear Valve(s). (� ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). " ❑ Dis enser Containment Floats)and Chain(s). Dispenser ID: e�` Dispenser' ❑ Dispenser Contain)nent Sensor(s). Model: �' ❑ Dispenser ontainment Sensor(s). Model: ❑ Shear Valve(s)-/ ' ❑ Shear Valve s,. ❑Dis enser Containment Float(s)and Chain(s). ❑ Dis enser 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,I have also attach 5d a copy of the report;(check all that applv): ❑System set-up ❑ Alarm history report Technician Name(print): /r�D, IV�mmn Signature: Certification No.:nn(_S License.No.: 90 —ZI4//J7• Testing Company Name: 1RC)cDA Phone Noj o9 ) q44-0/)a- Site Address: Date of Testing/Servicing: 001 Page 1 of,3 03/01 Monitoring System Certification B. Results of Testing/Servicing