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<br />MONITORING SYSTEM CERTIFICATION 2 7 2014
<br />For Use By All Jurisdictions Within the State of California
<br />Authority Cited.- Chapter 6, 7, Health and Sgfaty Code; Chapter 16, Division 3, Title 2��t�IVIVICIYI FiLens
<br />This form must be used to document testing and servicing of monitoring equipment. 44-mere-Ehan-one-mon �r �tvtG�Yl Fri
<br />;he 46i kyr-rrA sepamle certification or =or( mils}, he nreunrcd ch monitoring v..91Mc^ntrol pang by the technician who performs the work.
<br />A copy of this form must be provided to tho tank system owner/operator, The owner/operator must submit it copy of this form to the local agency
<br />regulating UST systems within 30 days of test date; be-l'""khi-R"
<br />A. General Information
<br />Facility Name:
<br />Site Address;
<br />Facility Contact Parson:
<br />Makafflodel of Monitoring System;
<br />B. Inventory of Equipment Tested/Certified
<br />Task JR
<br />❑ In -Tank Gauging Abe.
<br />Model;
<br />Annular Space or Vsuh Sensor,
<br />Model:
<br />Piping S=P / Trench Scnsor(s),
<br />Modclr
<br />[ Fill Sump Stnsor(a),
<br />Model:
<br />i iMOhmkieal Line Lcak Detector.
<br />Model:
<br />Picetronia Lino Leak NW -Mr,
<br />Model:
<br />❑ Taak Overfill / 14igh-Levo1 Sensor.
<br />Model:
<br />Other (speedoquipmont type and model in Section 13 on PlD:
<br />�Tank
<br />model in Section
<br />In -Tank Gauging probe.
<br />Model:
<br />Annular Space or Vault Sensor,
<br />Model;
<br />piping Sump I Trench Sensor(s),
<br />Model -
<br />Pill Surae Sensor(s).
<br />Modcl:----"`�
<br />Mechanical Lino Leek Detector,
<br />Model:
<br />Elmnnie Line Leak Detector.
<br />Model:
<br />Tank overfill / High.Levcl Sensor,
<br />Model;
<br />C1Othcr (specify equipmenI.OW and
<br />model in Secuon 13 on Pana 2),
<br />Dispenser IA; 1-_
<br />CI, Other (apc,4' equipment type and Modal in Section G on Yagc 2).
<br />❑ Dispenser Contsinmenl Sensor(,).
<br />Model;
<br />w wVelve(s).
<br />Model;
<br />LD1,POWTContainment Float(s) and Chain(s).
<br />Dispenser to: r
<br />❑ Daspan6er Contsiturtent Sattsor(s), Model;
<br />It Shou VWVZ(,),
<br />- Dispenser Containment Fiwt(s) and Chain(,).
<br />blspeh/er ID:
<br />IJiapeziser Camtaialrtrnt Scamor(s), Model:
<br />�] Shear Valva(,),
<br />❑
<br />Dispenser Containment finals) and Cbain(s),
<br />•11'the facility contains more Mnks ori spensers
<br />c th
<br />Bldg. No.:�
<br />City: ltiC V 7A p.,
<br />Contact P> One No.
<br />Date of Testiag/Sorvicing:
<br />Tank.ID: 11.11..
<br />©,L -Tank Oeuging Probe,
<br />Model:
<br />Annular Space or Vault Sensor,
<br />Model:
<br />i� Piping Sump / Tmnch Sensor(s).
<br />Model:
<br />Fill Sump Sensor(s),
<br />Model;
<br />Iff Mcchanicel Line Leak .Detector.
<br />Model:
<br />13ea
<br />ElegMnic Line Lk Detector.
<br />Modal:
<br />ID Tank Overfill / High -Leval Sensor,
<br />Model:
<br />11other (specify equipment type and
<br />model in Section
<br />Eon Pap 2).
<br />Tank W:
<br />0 In -Tea (Jau&g probe.
<br />Model:
<br />C3 Annular Space or vatilt Scnsor.
<br />Model;
<br />piping Sump I Trench Sensor(,),
<br />Model;mts
<br />❑ Pill Sump sor(s),
<br />Model:
<br />I� Mechanical Line LA k Pei eetar,
<br />Model:
<br />Q 1310ctr001e Lino Leak Detector.
<br />Model:
<br />❑ Tank overfill t High-Levoi Sensor.
<br />Model:
<br />CI, Other (apc,4' equipment type and Modal in Section G on Yagc 2).
<br />Dispen/er m; .,.
<br />[7j afapertzter Conralnment Sonsor(j)•
<br />Model;
<br />Shear Valve(,),
<br />Dispenser Containment Float(s) and Cht n(s).
<br />Dispenser ID:
<br />Q Dispenser Conm m Sensor(!).
<br />m
<br />Model;
<br />Shear Va1Yo(s),
<br />Dispenser Containment Floats) and
<br />ChWn(s).
<br />Dispen/er II);
<br />❑ Dispenser Containment Sensor(s).
<br />Moder;
<br />�] Shear Valva(/),
<br />❑ DisDeasct Cootalnmmt Float(,) and Chain(,),
<br />, oMY is forin. Include infbrmtttion for every tank and dispenser at the fhcility.
<br />C• Certification • I ctrdfv
<br />uidelines, ♦bat the equipcAtJon IS I Fdontlfietl In bels document w'aa ins"eted/serviced in Accordance with the ruanufacturer/'
<br />correct and &�bed to R showing
<br />cation is informatlon (e.g, mmufseturer/' checWisb) aece/!Ar
<br />l�g!`Plan shoNinQ the layout of monitoring a uipment ger an a �' verify that this information ie
<br />also attached A copy of the report; (check all that y q4l meat capable of generatln such rope
<br />►')� System set-up VAlarM hi�atory re �!r I have
<br />Technician Name (print); Tory Fantarist �lR ZV
<br />C. ati I N '�/.� A j signal=.
<br />ase ICC s2892MUT ln� e
<br />Testing CompanyName:U.S,T. C i e a A- 64d2 8 1
<br />Tes - p y Address: psane Teatin Inc. phone No.: saQ a>♦ -pass
<br />flag Company ip, Box 680 Cores CA 95307
<br />Date ofTesting/Servicing:
<br />wWw.Unldr ....
<br />S II •d ZD7289t':01 96,LTT2S602 3DN1dI-1dW0-_1 iSr1:W0d_d SS:lit t7TO2-b6-AHW
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