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MONI G SYSTEM CERTIFICATION For All Jurisdictions l Within the State of Califo. Authority Cited: Chapter 6 7,Healt Safety Code;Chapter 16,Division 3, 2WIe 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A sevarate certification or a etwrt must be f or each monitoring system control nain1 by the technician who perform 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 Informati n Facility Name: Ar /� � 4 Bldg.No.: Site Address: �G�1� i 4_�--d ®4 C L d., g�, City. �j 1�. ," �' Zap. 17 Facility Contact Person: � Z p Contact Phone No.: Make/Model of Monitoring System: 'L�, Lgj� r �. Date of Testing/Servicing: E B. Inventory of Equipment Tested/Ce ed Check the a ronate boxes to indicate s W ui ment serviced: Tank ID: S >�✓ln Tank ID: ❑ in-Tank Gauging Probe. Model. ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: N(Piping Sump/Trench Sensor(s). Model: — ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other ent type and model in Section E on P e 2 . ❑ Otherequipment ty1v and model in Section E on Page12). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: LlAnnular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sens ❑ Fill S Sens or(s). Model: �p Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Madel: ❑ Tank Overfill/High-Level Sensor. Model: 1❑ Otheaui ent Mx and model in Section E on P e 2. ❑ Other ent and model in Section E on P e-2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Containment FI s and Chains. ❑ 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). ❑ Containment FI s and Chain(s). ❑ 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). QDi%xnscr Containment FI s and Chains. ❑ 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 the facility. C. Certifl'CatiOn-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 equipment. For any equipment capable of pnerating such reports,I have also attached a copy of the NNUL&heck all that apply): ❑System setup to a ort Technician Name(print): Signature: Certification No.: License. :- Testing Co ' mPany N nine: +��. �"��rn 1p„ALw A �-tl f }Cay Phone No.:(�) Site Address: Date of Testing/Servicing: Page 1 ofJ' 03/01 Monitoring System Certification