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Appendix -VI.
<br />(Copies of Monitoring System ificat)onform and.UST Monitoring Plot. Planavailabl //www.waterboards: ov.
<br />• .. �•.._.. ,_._ CERTIFICATION-
<br />_........
<br />For Use By All Jurisdictions Within -.,
<br />MONITORING SYSTEM '00""EIVED
<br />u the State of Callfomia '
<br />Authority Cited:' Chapter 6 7, Health and Safety Code; Chapter 16; ,Div/sion•3, Title 23; Callfornia Code c@ T
<br />Regulatlons 2013
<br />each I'monitpdng system control panel by the technlclan' ho performs he .. A copy of this form mus n e report must be
<br />This form must .be Used to document testi and servicing of monitoring equipment. A se separate certiflcatlo
<br />t be provided to the to 'MENTAL YEALTH
<br />owner/operator. The owner/operator mustsubmit a cop of thisfonrrto the local agency regulating UST:systems wlthin.30 days of test I�/
<br />8 ES
<br />A. General Information - ,%fir
<br />Facility. Name: >� 4. !�/ ERWC
<br />Bldg. No,:_ iell ✓ ' '
<br />Site Address: ��! d f City: 21p:
<br />Facility Contact. Person -� � L m i t Contact Phone No.: -
<br />n�5
<br />Make/Model; of:Monftor(ng System: ,_ l �) ) �t� Date of Testing/Servicing:
<br />B., . : inventory of Equipment Te.stedlCertified
<br />Cheek the ro rlate'boxes to lnd(cate s ecific a ui ment ins ected/serviced:
<br />Tank ID: ' Tank•it):
<br />L • In' -Tank Gauging Probe. Model;' to In -Tank Gauging Probe. Model: •
<br />. AnnularSpace or,Vault:Sensor. Model: � ❑' ,AnnularSpace 'or Vault Sensor. Model,'
<br />Piping Sump-/ Trench Sensor(s). Model: ❑ Piping Sump/. Trench Sensor(s). Model
<br />'C . Fill Sump'Sensor(s). Model: ❑ Fill SumpSensor(s). Model
<br />C Meclianicai'UneLeak,Detector. Model: ❑ Meohan(cafOne Leak Detector. Model: •-
<br />X . Electronic UrieLeak Detector. '.: Model: ❑ Electronic Line Leak Detector... Model:
<br />C Tank:Overfill / High -Level Sensor. '. Model: ❑. Tank Overflli:/ High -Level Sensor. Model:
<br />:C..:O.tW. s eci . e I ent. a and model •inSection E on Pae 2). 0. Other s ecif uI ent t e and model in•Seoflon Eon PJe2
<br />7enk 1D: Tank IDc
<br />f-. In -Tank Gauging Probe. Model: n In -Tank Gauging Probe. Modell
<br />;1 Annnul#rSpace.or Vault Sensor. Model: u Angular Space or Vault Sensor. Model.
<br />C PipfiinotLimp/Trench`Sensor(s), Model: ❑ Piping Sump:/.Trench'Sensor(s). Model:
<br />C -Fill Sump Sensor(s). Model: ❑ Ftil,Sump Sensor(s).. Model.*.
<br />C Mechanical Line Leak Detector. Model: ❑ Mechanical Una Leak Detector. Model:
<br />C Eleclron(c Line Leak'Detecior. Model: .0 Electronic Line Leak -Detector. .. Model:
<br />Qverfllf%,Edigh l spah.Sansor , Vpdol: , ❑ Tank Overfill�-High-4evel.Sensor Modal; '
<br />C . Other. s ecl e ( ant a and model (n Sectlon E on Pae 21. ❑ Other s sci ui menet a and model In Section E on Page 2 :
<br />Dlsrpensi3t iDt ... .. .,
<br />Dlspenserl4
<br />L:.Wpehser Containment Sensor(s). Model: U• Dispenser Contalgment Sensor(s). Model:
<br />C . Shear.Vaive(sj. ❑ Shear Valve(s). .
<br />C :. pis ser Containment Floats and Chaln s . ❑ Dispenser Containment Floats and Chaln s .
<br />Disp anei r ID \ Dlspenser ID
<br />Cbhtainnioht Senspr(s): Model. 0 p(&penser Containment Sensoria). - Model-
<br />• f= Shear ValJa(s), , , •, , ❑ ShaarVa7ve(sj. _
<br />C -.DIs ..e nserContainment:Hoat s .and Chain s -. D- Dis enserContainmentFloat s anis Chale s
<br />Diap, Wr'.ID: LODaDp
<br />nser 10:
<br />C i�ispenser Containment Sensor(a). Modal: penser.Containment Sensor(s). ModeG
<br />1, Siaeai?UalVe(a).:.:_ ear..Va .;�1]IlditLc3&t3Lt3.,i�t S - ' - & �•--.___ �r _,=�: m�-
<br />'If theaIUt� contains more tanks alispanoars copy this form. include infotmotion for syerai tonlSand-dispenser at thp,facifty,-„
<br />r. OaCtlfil aflcth_Lcertift%that the aqulpment_tdentM&Un-this:docuihent..was-Jngooctad/serviced-in_acorft` Once.wlth the ►riapufacturers=—,------.--
<br />„ggidelines. Attached;,to,this,Go lfltatipfl ls'infotntoil n.(e.g,'manuticturara' checklwtp) necessary tc..verify.that hIs.informattpp Is correct:
<br />and: a Plot Pian showing, tho layout of monitoring'epuipment. For any equipment :capable of g®nerating spch reports, l have slag ettaGhed a
<br />.. __- ' Alfa teperE¢d'xld�call ik;ftMitl�(Y� - SY.atemt Ap l AtfltttlstgfY31
<br />r..r--:.:.-.a...:a.xq,. t.+t .k.d1 A'!Y'r!. �.4'v Nanat..,i.•r ...v uwwY, qmb r .,rny .((. :rxa: .ta,.giw,... rt.a* ,,. ,,,+++ it :yG/r r .v. ar. v. n,....r - .+..n a.0>.
<br />Technician Name (print) �Iy at(/, Signature: 4C�%®
<br />Cerftflcat(onNo / License. No..
<br />.No a
<br />Testing Company Name L / Phone_No.
<br />Te'sting`CompanyAddtess: Z5 � x,166 1 �r✓� Date of Testing/Servicing: � 1,_/
<br />Monitoring System Certification r Page I of 4 12/07
<br />1 2/21/07
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