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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 orepared 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 Information Facility Name: O Bldg.No.: Site Address: `7 �� City: C-/ Zip: Facility Contact Person: q Contact Phone No.: ( ) Make/Model of Monitoring System: e'(',*. j�n�-TI 5 Date of Testing/Servicing: -S / �rl B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: Tank ID: 7 In-Tank Gauging Probe. Model: 77 In-Tank Gauging Probe. Model: V 7 Annular Space or Vault Sensor. Model:, 94 icf -4/05' Annular Space or Vault Sensor. Model: —7P/3i0 Q5f Piping Sump/Trench Sensor(s). Model:-X`f 3bU 1--e-S Piping Sump/Trench Sensor{s). Model:7<L/ ��;t• '�� Fill Sump Sensor(s). Model: ze-' Fill Sump Sensor(s). Model:',�i'`�35�� yrs b Mechanical Line Leak Detector. Model: b Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: e- E' I ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Cl Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment tv a and model in Section E on Pate 2). ❑ Other(specify equipment tv a and model in Section E on Paee 2). Tank ID: Si_i Tank ID: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Y q7 5 Annular Space or Vault Sensor. Model: ' - I]� Annular Space or Vault Sensor. Model: Piping Sump I Trench Sensor(s). Model: —740 tint _'t`J Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model-.-7 q4 %"I c'J Fill Sump Sensor(s). Model: n,4 j-R�, ,?z:E- ❑ Mechanical Line Leak Detector. Model: ❑,Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: C'0 1 ❑ Tank Overfill/High-Level Sensor. Model: �Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecifv equipment tv a and model in Section E on Page 2). ❑ Other(specify a ui ment ty2e and model in Section E on Page 2). Dispenser ID: f� ^` Dispenser ID: 3`ly fel Dispenser Con Lai nment Sensor(s). Model: G`f es zz Dispenser Containment Sensor(s). Model: i f`/-5 ae, 'Shear Valve(s).Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ispenser ID: �)— Dispenser ID: <- Dispenser Containment Sensor(s). Model: f 7T� ='cf Dispenser Containment Sensor(s). Model: hspenser ear Valve(s). Shear Valve(s). Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)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 Floats)and Chain(s). ❑ Dispenser Containment Floats)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 eq ipment. 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): John COUrant Signature: Certification No.: C/.F- — 0 -- 6)5,5 4�f- License.No.: 1 R44Rf) _ Testing Company Name: Scott Co of Cal i forni 3 Phone No.:1;—gig RqS—�RRR Y JR5 Site Address: Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification