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Ohlelds, Harper MONITORING N 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 p erepared 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 / Facility Name: ` Bldg. No.: Site Address: . e City: 2 Zip: Facility Contact Person: Contact Phone No.: () Y 78 ®5.s"/,j Ivlake/Model of Monitoring System: -35Z Date of Testing/Servicing: ! //8 /.0/ B. Inventory of Equipment Tested/Certified �f - Cheek theappropriate xis to indica specific ui mint inspected/serviced. 609,/ ! �� 2-1 7a Q( Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: AD "Id ❑ In-Tank Gauging Probe. Model: Y 72 Yo-/6` ❑ Annular Space or Vault Sensor. Model: ? O ~ V2C ❑ Annular Space or Vault Sensor. Model: t eg- vi Piping Sump/Trench Sensor(s). Model: 71 5U2 42 2 0 ❑ Piping Sump/Trench Sensor(s). Model: _�6 je ❑ 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 equipment type and model in Section E on Pa 2). ❑ Other LsZEify ui ment type and,model in Section E on Page 2). Tank @: Tank ID: ❑ In-Tank Gauging Probe. Model: V 09 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: C9q26 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: - p ❑ Fill Sump Sensor(s). Model: Q 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(specify-equipment e and model in Section E on Pagel).— ❑ Other(specify ui t=and model in Section E on Page 2). Dispenser ID: 41f Dispenser ID: .- ❑ flispenser Containment Sensor(s). Model: _ 12Dis nser Containment Sensor(s). Model: Wr S Valve(s). ear Valve(s). lr5i nser Containment Float(sl and Chain s). ❑'ISisr ser Containment Flo s}and Chains. Dispenser ID:_ 3 Dispenser ID:_ 15o" W ❑ Di er Containment Sensor(s). Model: ❑ D' enser Containment Sensor(s). Model: �ar Valve(s). S alve(s). user Containment Floats and Chains. is eraser Containment Floats and Chain s). Dispenser ID: 7Dispenser ID:_ /b 13 Di Containment Scnsor(s). Model: ❑ D' nser Containment Sensor(s). Model: Valves}. Shear Valve(s). 2151spenser Containment Floats and Chains. eraser 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. manufacturerFq necessary to verify that this information is correct and a Plot Pian showing the layout of monitoring equipment. For anyment ca ble of generating such eports t ha also attached a copy of the re rt;(chock atf t a t a y): ❑ System set-upAI r is ryrep114 Technician Name(print): Qvt,, Signature: gz— Certification No.: License. No.: Testing Company Name: Phone No.: ) 6 5-2- Z/9 W Site Address: U i� !/ Date of Testing/Servicing: Page 1 of 4 t}3/t)1 Monitoring System Certification