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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 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 Information p ' Facility Name: C /-,-� L� Bldg.No.: Site Address: 12 1 /)1 X '114— City: S 16G !b 4 Zip: Facility Contact Person: E5a-) Contact Phone No.: Make/Model of Monitoring System: /L-5 Date of Testing/Servicing: B. Inventory of Equipment TestedlCertified Check the aegrogriate boxes to indicates ific Equipaent ins serviced: pk ID: y T� M ayk ID: t i3 In-Tank Gauging Probe. Model: Ih,t 9 " EtX-Tank Gauging Probe. Model: le J 1 idj Gnular Space or Vault Sensor. Model: cu C, 13Xnnular Space or Vault Sensor. Model: .s c C3 Piping Sump/Trench Sensor(s). Model: ,90- ff Piping Sump/Trench Sensor(s). Model: 2 j ❑ Fill Sump Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: f-I'Mechanical Line Leak Detector. Model: FF z 6?v 3 fGiv I; ❑ Mechanical Line Leak Detector. Model: rk �kofj ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/i•Ii��or. Model: PA,r t-/ fe,' ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify ui ent type and model in Section E on Pae 2)- Tank ID: P/1(---s 4 Tank ID: ElIn-Tank Gauging Probe. Model: /"h i ❑ In-Tank Gauging Probe. Model: Q�A—nnular Space or Vault Sensor. Model: 'i 'o ❑ Annular Space or Vault Sensor. Model: ZI Piping Sump/Trench Sensor(s). Model: u q ❑ Piping Sump/Trench Sensor(s). Model: ❑ iIl Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: @S Mechanical Line Leak Detector. Model: -SG-;b I-) ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Lr'Tank Overfill/High-s-ff2Rnsor. Model:t-/, ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui ment type and model in Section Eon Pa e 2). ❑ Other(s cify Nuiement t and model in Section E on Pa Dispenser ID: Z-- Di nser ID: [�DispenserContainment Sensor(s). Model: -SMAO-T SerispenserContainmentSensor(s). Model: S ar Valve(s). L7,Shear Valve(s). ispenser Containment Float(syand Chain(s). Cf Dispenser Containment Float($)and Chain(s). Dispenser ID: '/G DDiWenser ID: ' lV'DtspenserContainment Sensor(s). Model: UpispenserContainment ensor(s). Model: E3�Shcar Valve(s). . ear Valve(s). Dispenser Containment Float(s)and Chain(s). U Dis enser Containment Float(s)and Chain(s). Fea ' r ID: r f Dispenser ID: /// nser Containment Sensor(s). Model: 5 W r»; 56.E F,.r _ E3 ispenser Containment Sen r(s). Model: Valve(s). Gear Valve(s). ser Containment Float(s)and Chain(s). is 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' cheddists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring eq meet For any eg �capabbllef generatin 0.1 reports,I have also attached a copy of the reportL check all that apply): System set-up CJ repotTechnician Name(print): J- C a!t Ga��°"� Signature: �—"' Certification No.: TRIANGLE ENVIRONMENTAL, INCb�,7SLicense.No.: 001- 4�We l 2525 W. BURBANK BL Testing Company � _2H2 W. Phone No.: Site Address: jj Date of Testing/Servicing: C'- Page 1 of 3 03/01 Monitoring System Certification