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Appendix V1 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hYp;lLvvww.waterboards.ca.gov_) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited.,Chapter 6.1, 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 prepared 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 lniormaQon Facility Name: -V ckr11r' ll a L"0 Bldg.No.: Site Address: (tn. L.z 1 11�I.rp� City:�i��tta. T Zip: Ll 5-3 3 7 Facility Contact Person: �Yf^erowt Contact Phone No.:(.To 4 ) !a-L!1• Zl Ga „y Make/Modal of Monitoring System: Z'L5-STD _ Date of Testing/Servicing: B_ Inventory of Equipment Tested/Certified Check the appropriate boxes!o indicates ecific equipment fns acted/servlced: TankID: R1 Tank ID: % In-Tank Gauging Probe, Model: 7il. in-Tank Gauging Probe. Model: Annular Space or Vault Sensor, Model: Annular Space or Vault Sensor. Model- Piping Sump/Trench Sensor(s). Model Piping Sump/Trench Senscr(s). Model: Z bB KFill Sump Sensor(s). Model: Zo p Fill Sump Sensor(s). Model: L611, 1 Mechanical Line Leak Detector. Model ( U Mechanical Line Leak Detector. Model: Kl Electronic Una Leak Detector. Model:�Sr_ -V/ rK Efectronic Line Leak Detector. Model: VIR ft Tank Overfill i High-Level Sensor. Model: - Tank Overfill I Hign•Level Sensor. Model:v/Sh I_. Others ecif equipment pe and mode{in Stiction F on Pa e 2. U Other(specifye i ;hent type and model in Section F on Page 2)_ Tank lD: Di C-SR,I_ Tank ID! M In-Tank Gauging Probe. Model: IL In-Tank Gauging Probe_ Model, Annular Space or Vault Sensor. Model:,4,)- A _ r Annular Space or Vault Sensor, Model Piping Sump/Trench Sensor(s). Model:.yAts r; Piping sump/Trench Sensor(s). Model: lyj FIR Sump Sensor(&). Model ZAS_ D Fill Sump Sensor(s). Modal: I i Mechanical Line Leak Doteetor. Model: D Mechanical Line Leak Detector. Model: fg Electronic Line Leak Detector. Model::. _ D Electronic Line Leak Detector, Model: '(t Tank Ovarfili/High-Level Sensor. Model; u►P, U Tank Overfill/High-Level Sensor. Model: Other(s ecif a ui rent type and model in Section F on Pae 2 fl Other(specily(specifyequipment type and model in section E on Page . Dispenser ID: Ikl- Dispenser ID: Dispenser Containment Senaor(s), Model:Zsg % Dispenser Conta nment Sensor(&)_ Model: Shear Vaive(s). fV Shear Valve(s). « i Dispenser Containment Float(s)and Chain(s). rl., Dispenser Containment Float(s)and Chain(s). Dispenser ID: Sit Dispenser ID: It C It Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s), Model: ILa Shear Valve(s). [�( Shear Vafve(a), Q Dispenser Containment Floats and Chaln s. U Dispenser Containment Float(s)and Chains. Dispenser ID:_OW-9 Dispenser ID: Dispenser Containment Sensor(s). Model:-1.WK )t Dispenser Contalnmant Sensor(&). Modal oft rf Shear Valve(s). :=yt Shear Valve(s). o Dispenser Containment Float(& and Chains o Dispenser Containment Float(s)and Chaln s. If the facility contains more tanks or dispensers,copy this form- Include information for every tank and dispenseir at the facility, C_ Certification - I certify that the equipment ldentiffe0 In this document was Inspected/serviced In accordance with the manufacturers' guldelfhes. Attached to this Certification Is Information(e.g.manufacturer 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 attached a copy of the report;(check all that apply): )9 System set-up -f Alarm history report Technician Name(print): SJeSt Certification No.: 1 L• ecc�tt e No Testing Company Name; Testing Company Address: `I i Date of Testing/Servicing: 17./7. / monitoring System Certtncatton Page 1 of 4 7tipy 2/21/07