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t (moi MONITORING S l,STEM CERTIFICATION For 'Use By All Jurisdictions Within the State of California Authonry Cited: Chapter 6.7, Health and Safer), 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 Infor ation Facility Name: Bldg. No.: Site Address: er Ln City: Zip: Facility Contact Person: (0"jy)^t" Contact Phone No.: ( )01 C1,5 r"%ok6o Mike/Model of Monitoring System: Date of Testing/Servicing: Q /_/ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: ® Tank ID: kAeMe In -Tank Gauging Probe. Model: K 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 Sensor(s). Model 164 Q&_ ❑ Fill Sump Sensor(s). Model: IX Mechanical Line Leak Detector. Model: Fill Sump Sensor(s)'. Model: _ Mechanical Line Leak Detector. Model: m O Electronic Line Leak Detector. Model: ❑ Electronic Line.Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (sRELify equipment t and model in Section E on Pa e 2). ❑ Other (s2Eify equi ment = and model in Section E on Pa a 2). Tank ID: R I Tank ID• In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: Annular Space or Vault -.sensor. Model: ❑ Annular Space or Vault Sensor. Model: TA Piping Sump /Trench See sor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Model: A f� ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Leve] Sensor. Model: ❑ Other (sgEify equi ment type and model in Section E on PaFe 2). ❑ Other (s ecify equipment type and model in Section E on Pae 2). Dispenser ID: , Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). 16 Shear Valve(s). Dis enser Containment Floats) and Chain(s). Dis nser 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). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser TD: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Ok Shear Valve(s). ❑ Shear Valve(s). ispenser Containment Float(s) and Chain(s). ❑ Dis enser 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 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' checklist`) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equi Pment capable of generating such reports. I have also attached a copy of the report- (check all i t apply): t OK—system set-up larm history r ort Technician Name (print): ®Milt qjj—� tt Signature: JAna Certification No.: License. No.:_� Name: �1`r Phone No j } 4 Testing Company L Site Address: Date of Testing/Servicing: Page I of 3 03/07 Monitoring System Certification