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MONITORING SYSTEM CERT CATION 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 Facility Name: ✓ ► m Bldg. No.: Site Address: �y� t►/. �''%✓©%W v 57, City: AA Zip: Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: xf C Date of Testing/Servicing: 6/_ //c� B. I ventory of Equipment Tested/Certified 7' 1?�3 Che c the appropriate boxes to indicate specific equipment ins ected/serviced: ID: 7 T ID: Gauging Probe. Model: " ' _ -Tank Gauging Probe. Model: %►}A S 1—� FTank nular Space or Vault Sensor. Model: F Annular Space or Vault Sensor. Model:ping Sump / Trench Sensor(s). Model: o? U Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: _ Model: R Ll wi Sump Sensor(s). Er Mechanical Line Leak Detector. Model: Model: � ❑ Electronic Line Leak Detector. .-T�`�Z-- Model:' ❑ Fdectronic Line Leak Detector. a- Model: J Tan erftll / Hig'(i-TZ -m. Model: Q'Tank Overfill/ m3sor. Model: �4,,6U ❑ r (specify equipment type and model in Section E on Page 2). ❑ Other (s i ui ment and model in Section E on Page 2). Ta ID: Tank ID: EllIn-Tank Gauging Probe. Model: AA C v t--- 0 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: ❑ 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: Q'Tank ank Overfill / Hig . Model: W(, /:se ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify ui men and model in Section E on Page 2). ❑ Other (specifx 2quipment t nd model in Section E on Pae 2). Dispenser ID: 1'T Dispenser ID: > zz/ ❑ Dispenser Containme t Sensor(s). Model: 13 Dispenser Containment Sensor(s). Model: el`S�& Valve(s). O'Shear Valve(s). Qr6ispenser Containment Float(s) and Chain(s). UrDispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: L3 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Oa nser Containment Float(s) and Chain(s). 0 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. 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. nufacturers' checklists) ,necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equ' ent. For any equip capable of generatin%reports, I have also attached a copy of the reporti check all that apply): I System set-up ory repot Technician Name (print): l - C C>w 12_4"/ Signature: Certification No.: TRIANGLE ENVIRONMENTAL INC. %SLicense .No: �9oZ `/ ZDZ0 VV. bUKbANK MU.� Testing Company Z OBANK, CA _ Phone No.:( Site Address: Date of Test ing/Servicing: _/,� Page 1 of 3 03101 Monitoring System Certification