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MONOORING SYSTEM CERTIFIOA'TI® _) For Use By .411 Juriseliclions 1f ilhin the ,State gfCalifornia � ,r Ailthor•iry Cited: Chal-Ver 6.7, Health and Sbfetl) Code; C'halver 16, Division 3, Title 23, California Code of 1 c lrlcrNor ',y 7 This form must be used to document testing and servicing of monitoring equipment. A separate certificatrotibrjie' [' rt tausfib �nasr rp r prepared for each monitorinystem control panel by the technician who performs the work. A copy of this fora: st;be proVrd�d t - the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST sysfei Within 30 days of test date. A. General Information Facility Name: Bldg. No.: Site Address: r- ! Ci "� �'� Zip: E� Facility Contact Person: Contact Phone No.: 11a Make/Model of Monitoring SysTem: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the iVpropriate boxes to indicates ecific a ui ment ins ected/serviced: Tank ID: Tank 1D: ® <,- pea77— LJIn-Tank Gauging Probe. Model: ElIn-Tank Gauging Probe. Model: /^;.° ❑ Annular Space or Vault Sensor. Model: 7'-9ff 3 4011—' 5<®�K ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: 74'q(3 ❑ 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 (s ecify S meat type and model in Section E on Page 2). ❑ Other (specify a ui ment t e and model in Section E on Page 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: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: Other (s ecif equipment t e and model in Section E on Page 2). LIOther (s ecif a ui ment t e and model in Section E on Page 2). ID: 7 Dispenser ID: j rDispenser Dispenser Containment Sensor(s). Model:r� -S - ❑ Dispenser Containment Sensor(s). Model: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: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser 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). ❑ Dispenser Containment Float(s) and Chain(s). *I1'the facility contains more tanks or dispensers, copy this form. Include C. Certification information for every tank an dispense at the facility. Yr r - f"-) I "' g - I certify that the equipment identified in aent this docu gas inspected /scrvicean 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 e ' ment,, apable of generating such reports, I have also attach d a copy of the report; (check n/Ilial app/t): ❑ Syst e -ti h` m history report Technician Name (print): T �� D, �,1'00mr1 Signature: � s Certification No.: n(005 License. No.: 96 j�13 Testing Company Name: tcr5) e fJ7 Phone No.:G!-g ) 9'�eN- Site Address: 6 (1 r Date of Testing/Servicing: Page Monitoring System Certification 1 of 3 - 03/111 D. Results of Testing/Servicing