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'V"CONITORING SYSTEM CERTIFICATR.-I)IN RD J�C�VV �LU F w & AH Jul J c/iclions 14whin the „tate gl'Culi;a e qq „ .Authority Cited: Chapter 6.7, He,, ,t and 5'gfeh) Code,: Chapter 16, Division 3, Title Ccrlifitrnicr C.�rx1e V9fiYcnttuX�00$ This form must be used to document testing and servicing of monitoring equipment. A separate certifi�Q� �Tii li H pt•epared for each monitoring system control panel by the technician who performs the work. A copy.of this forrR5.RMJ 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 Information Facility Name: C' M— S Bldg. No.: Site Address: /� `� 1 C, ��25��,-HiT�•= City: /vc,q,„i'Eic/ Zip: Facility Contact Person: Q" Contact Phone No.: ( ) Make/Model of Monitoring System: '"10 i S0 1 Date of Testing/Servicine: -:T / / e.)A B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seri iced: 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). * Ifthe facility contains more tanks or dispensers, copy this form. Include information for every ta,ik 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. manufactm-ers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equip� ent. For any equipn rat capable of generating such reports, 1 have also attached a copy of the report; (check u!/that app/t): �Syste n set-up Alarm history report Technician Name (print): AVi 1Z�f t it k/r�Signature:// / Certification No.: License. No.: /I Testing Company Name: a hA i'57, Phone No.:( Ztrt ) %~/AI. 4112. Site Address: iT3 _�� y(i JVt�' -eI Date of Testing/Servicing: Page 1 of3 1!3/UI Monitoring System Certification 91, D. Re.•,uhs of Testing/Servicing ssC_ M0 Ta Ic 1 D: v G TaID: h n -Tank Gauging Probe. Model: � ,k -Tank Gauging Probe. Model: -Annular Space or Vault Sensor. Model: ranular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 7 C, �' Piping Sump / Trench Sensor(s). Model: ❑ fill Sump Sensor(s). Mechanical Line Leak Detector. Model: _ _ _ Model: "jC^� ❑,Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: i l ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s )ecify e ui ment type and model in Section E on Page 2). ❑- Other (specify equipment t e and model in Section E on Page 2). T. k ID: '. Tank ID: -Tank Gauging Probe. Annular Space or Vault Sensor. Model: Model: 3 f3 ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: ' cl ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: ix i ❑ Mechanical Line Leak Detector. odel: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s iecify equipment type and model in Section E IIIPage 2)- ❑Other (specify equipment ty a and model in Section E on Page 2). D' •penser ID: t Z Di penser ID: �( Dispenser Containment Sensor(s). Model: ADispenser Containment Sensor(s). Model: Shear Valve(s). hear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser Containment — fi Di -7enser ID: Sensor(s). Shear Valve(s). Model: C Dispenser Containment Sensor(s). Model:, ❑ Dispenser Containment Float(s) and Chain(s). Sear Valve(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). * Ifthe facility contains more tanks or dispensers, copy this form. Include information for every ta,ik 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. manufactm-ers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equip� ent. For any equipn rat capable of generating such reports, 1 have also attached a copy of the report; (check u!/that app/t): �Syste n set-up Alarm history report Technician Name (print): AVi 1Z�f t it k/r�Signature:// / Certification No.: License. No.: /I Testing Company Name: a hA i'57, Phone No.:( Ztrt ) %~/AI. 4112. Site Address: iT3 _�� y(i JVt�' -eI Date of Testing/Servicing: Page 1 of3 1!3/UI Monitoring System Certification 91, D. Re.•,uhs of Testing/Servicing ssC_ M0