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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 scoarate certification or report must be oreoared for each monitoring system control Panel by the technician who perforins 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 InformationAee,� �� 6 Facility Name: Bldg. No.: Site Address: ? ;L/ a //- 44 e i ?N( 4 City: 1'77C <' 7?-) Zip: Facility Contact Person: Contact Phone No..- Make/Model o.: Make/Model of Monitoring System: I/R Z5 j Ty Dace of Testing/Servicing: Z Ll 7 l °( B. Inventory of Equipment Tested/Certified f`L....b •w.. ............;are h! vXeS to ;-N-1 c ririr rnuinment insneeted/servieed: Tank M: Tank ID: VL' ❑II 1 -Tank Gaugin; Probe. Model: ❑ In -Tank Gauging Probe. Model: eI ,4nnular Space or Vault Sensor. Model: I/Z y o7 CrAnnular Space or Vault Sensor. . Model:yIZ Y,;7 C3'fiping Sump / Trench Sensor(s). Model: /iiZ 2 0 Y O'Piping Sump /Trench Sensor(s). Model: L - i Z Zo Y ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: CRrElectronic Line Leak Detector. _ Model: -e Pf 123 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill-/ High -Level Sensor. Model: ❑ Other (specify equipment tv a and model in Section E on Parte 2). ❑ Other (specify equipment ty a and model in Section E on Paec 2). Tank ID: 4 0 K Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: _ E.. %nnular Space or Vault Sensor. Model: _ j _ ❑ Annular Space or Vault Sensor. Model: G-?iping Sump / Trench Sensor(s). Model: yJZ Z Or ❑ Piping Sump /Trench Sensor(s). Modcl: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: I -Electronic Line Leak Detector. Model: 23 C t T ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / Hi;h-Level Sensor. Model: ❑ Other (s ecifv couioment tviie and model in Section E on Parc 3). ❑ Other (specifv equipment tv c and model in Section Eon Pace 2). Dis user ID: t " Z ��jD,spenser Dispenser ID: PCispenser Containment Sensor(s). Model: 1( /C 7 0' t— Containment Sensor(s). Model: U Jllcar Valve(s). 01—hear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: 11�_ - 6 Dis riser ID: -7 ' r \ I''Dispenscr Containment Sensor(s). Model: cl/. eo l�Jl 'Denser Comalnnit:m Sensor(s). Model: TrSheur Valve(s). �J C ear VaIve(s). Cl Dis cnserContainment Floadsl and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: O Shear Valve($). ❑ Shear Valve(s). ❑Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at me tacuuy. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capabl generating such reports, I have also attached a copy of the report; (check all that apply): ❑ System set-up ClAlar t' y report Technician Name (print): John Schellenhach Signature: Certification No.: 344H License. No.: ]$ kn Testing Company Name: Scott Co. of California Phone No.:( S10 ) Rq9-2113 x '189_ Site Address: �,�� /Y- z4, e '�^'"r Date of Testing/Servicing: L/ I lel Page I of 3 03/01 Monitoring System Certification