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Monitoring System Certification Pagel of3 03/01 D. Results of Testing/Servicing MON RING SYSTEM CETIF TION I 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 syste5- 'within .he 30 days of test date. A. General Information , Facility Name: p ` 1 Bldg. No.: Site Address: 70 Q Q;C' ` d3r 1-t J✓ S®,c Cih` �, Zip: qb�_3 f Facility Contact Person: �3a S Contact Phone No.: ( ) Make/Model of Monitoring System: Vkt cor cam. 1-k4 SO r— _,L&VX Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the acerogriate boxes to indicatespecific a ui ment ins ected/serviced: nk ID: -- 1��`� aey, • ®. Tank ID: lJ r cQ5 ( % k 1-, fS In -Tank Gauging Probe. Model: FcU3 _ . ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: /��5 ❑ Annular Space or Vault Sensor. Model• � /;L Piping Sump / Trench Sensor(s). Model: Jy ❑ 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: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (seeciEy equipment t e and model in Section E on Pa a 2). ❑ Other (specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ 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: ctronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: k Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: er (s eci a ui ment t e and model in Section E on Pa a 2). ❑ Other (s eci a ui ment t e and model in Section E on Pa e 2). ser ID: Dispenser ID: penser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ar Valve(s). rDispenser ❑ Shear Valve(s). enser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). ser ID: Dispenser ID: penser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ar Valve(s). ❑ Shear Valve(s). enser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). ser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dis enser 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. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of he report; (check all that app&): ❑ Syst set p ❑ A � m histY►'ry r -e rt Technician Name `; y (print): �J t Signature: t %, Certification No.: (o — JJ License. No.: Testing Company Name: A0 r 6 Phone No.:( 0 �—L7 / I Site Address: a 0 Date of Testing/Servicing: J Monitoring System Certification Pagel of3 03/01 D. Results of Testing/Servicing