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Al1G 23 ' 01 8 : 05 FROM GEETTTLER RYAN TO 842 660 PAGE .002i004 MONITORING 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 ofRegulaaions This form must be used to document testing and servicing of monitoring equipment. A separate certification or retsort must be prepared for each monitoritt s stem control anel 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 forth to the local agency regulating UST systems within 30 days of test date. A. General Information d ! 7& 1 Bldg.No.: Facility Name: k em w yl - 4� c,3 City:� �� Zip: Site Address:f f. Z qb y3 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: L S 3-,--0 Date of Testing/Servicing: B. Inventory of Equipment'Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/servieed: Tank ID: Tank IA: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe, Mode}: Q Annular Space or Vault Sensor. Model: [3 Annular Space or Vault Sensor. Model: ❑ 'Piping Sump/Trench Scnsar(s). M ❑ Piping Sump/']'tench Sensor(s). Model: _ _ Ci Model: Fill Sump Sensor(s). odcl: 13 Fill Sump Scnsor(s). ❑ Mechanical bine Leak Detect Model: ❑ Mechanical Line Leak Detector. Model:_ ❑ Electronic Linc Leak D r. Model: ❑ Electronic Line Look Detector. Model: ❑ rank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High- vel Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). 13Oth cify ment type and model in Section E on Page 2}. Tank ID. Tank ID: t auging Probe. Model: ❑ In-Tank Gauging Probe. Model: ar Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: tping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Senser(s). Model: Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Linc]reek Detector. Model: O Mechanical bine Leak Detector. Model: a Electronic Line Leak Detector. Model: ,_ [I Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ "fartk Overfill/High-Level Sensor. Model: E3 Other(specify equipment type and modal in Section on Page 2). 13 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser IU: Mode• ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). ❑ shy Valve(s). ❑ Shear Valve(s). ❑ Dispenser Contaittmcut Float(s)and Chain(s). ❑ Dispenser Containment Float(s} Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment Sensor(s). Model: Cl Dispenser Containment sor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)sAd Chain(s). Q Dispenser Con went hloat(s)and Chain(s). Dispenser ID: Dispenser ID' ❑ Dispenser Containment Sensor(s). Model: ❑ D' r Containment Sensor(s). Model; ® Shcas Valve(s). ❑ S Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ispenscr Containment Flaat(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. with the C. Certification - I certify that the equipment identified in this documenmanufacturers,sinnchecklists)1serecessary to verify that this in accordance manufacturers' guidelines. Attached to this Certification es information (erg• information is correct and a Plot Pian showing the layout of monitoring eq ipneent. For any equipment capable of istory report ng such of the re rN c ck 1 that apply): Sy tem set-a reports,I have also attache a{�qPy p° 10 ature: tj � 1 [+CC OH1 Sign Tcchnician Name(print): �O ? Certification No.: License.No.: /f �Lr� Q„1��n c, • PhoneNo.: Z� > Sal ` '��77 Testing Company Name:. Date of Testing/Servicing: Site Address: 03/01 Page 1 of 3