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_ _. _ -,• ..,,,,. .,,. ,,� �v�•,pvJti�..r r it 1n rwuM RECEMnn W MONITORING SYSTEM CER.TIEI ATION 0 C T 15 2002 For Use By All Jurisdictions Within rite State of Califorplia A:rrlrority Cited: Chapter 6.7. Health and Safety Code: Chapter 16, Division 3, Title 23. Califor ff MftrgLTH p a This form must be used to document testing and servicing of monitoring equipment. A sevarate certifiGatloti Ye t ared for each monitoring system control Ranel by the technician who performs the work. A copy of this form trust be provided to the tank sy-tern c,wner/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 informa won Facility Name: ✓t tti6ti ✓'N'i Bldg. No.: Site Address: i Zip®: Facility Contact Person: Contact Phone No.: ( a 1 44- Make/Model of Monitoring System: 4-e A, k- 14-14- 1 Date of Testing/Servicing: / D ID / 02 B. Inventory of Equipment Tested/Certified Tank ID: L> r CS -1v O !n -Tank Gauging Probe. Model: a Annular Spacc or Vault Sensor. Model: .e Piping Sump / Trench Sensor(s). Model: O fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Modal: C3 Electronic Linc Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: O Other (specify equipment type and model in Section E on Page 2). Tank ID: O In -Tank Gauging Probe. Model: O Annular Spacc or Vault Sensor. Model: ❑ Piping Sump / Trench Scnsor(s). Model: O Fill Sump Scnsor(s). Model: O Mechanical Linc Leak Detector. Model: 0 Electronic Linc Lcak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment type and model in Section E on Paac l). Dispenser ID: O Dispenser Containment Sensot(s). Model: O Shear Valvc(s). O Dis2Snscr Containment Float(s) and Chain(s). Dispenser ID: O Dispenser Containment Sensor(s). Modcl. O Shear Valve(s). O Dispenser Containment Float(s) and Chain(s). Dispenser ID: O Dispenser Containment Sensor(s). Model: O Shear Valve(s). ,If the facility contains more tanks or dispensers, copy this form. include Tani; )D: O in -Tank Gauging Probe. Model: a Annular Space or Vault Sensor. Model: ir'Piping Sump/ Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: D Mechanical Lina Leak Detector. Model: O Electronic Linc Leak Detector. Modcl: Q Tank Overfill / High -Level Sensor. Model: O Other (specify equiErntent type and model in Section E on Paee 2). Tank ID: O In -Tank Gauging Probe. Model: D Annular Space or Vault Sensor. Model: O Piping Sump / Trench Sensor(s). Modcl: O Fill Sump Sensor(s). Model: O Mechanical Linc Leak Detector. Model: O Electronic Linc Leak Detector. Model: O Tank Overtiil / High -Level Sensor. Model: O Other ( ciffy equipment type and model in Section E on Page 2). Dispenser ID: O Dispeam Containment Sensor($). Model: 0 Shear Valve(s). 0 Vis eraser Containment Floaas.) and Chain(s). Dispenser ID: 0 Dispenser Containment Scnsor(s). Model: O Shear Valve(s). „ O Dis2enser Containment Floats) and Chain(s). Dispenser tD; O Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0. Dis2mser Containment Float(s) and Ch inn(s). nfotnut'son for every tank and dispenser at the facility. C. CertlfiCA011 -11 certify that the equipment identified In th document %vas inSpectedlserviced 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 Piot Pian sboeving the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the rt; (check out thatpply): O System set-up CI Alz history report Technician Name (print) ' W t `i �-rv` S _ Signature: Certification No.: License. No.: ® U Testing Company Name: . sNe. Phone No.: 464-8333 Site Address: == U Date of Testing/Servicing: / Page I or 3 Monitoring System Certification o Cil41 Va(X11 11�a q V �csra� 03/01