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ADD MONA01 RING SYSTEM CERTIFIAHON li(; pleV !'or Use By All Jurisdictions Within the State of Culi%rniu / � 2Q Authority Cited: Chapter 6.7, Health apd Sgfety Code, Chapter 16, Division 3, Title 23, Calyinrnia Code� I �5 This form must be used to document testing and servicing.of monitoring equipment. A separate certification or report must r�ttau 4iTh Ior each monitoring system control panel by the technician who performs the work. A copy of this Corm must be provided to tlt�k system owner/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 Information Facility Name: `� Bldg. No.: Site Address: itC' ty: Zip: Facility Contact Person: Contact Phone No.: (_�dr) Make/Model of Monitoring System: Date of Testing/Servicing: /Z Zi0�'— B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID:_ !iTank ID: Ain-Tank Gauging Probe. e Model: ,dQn-Tank Gauging Probe. Model: _ Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: ZV Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Z03i, X-Mechanical Line Leak Detector. Model: Z,,d Z0d%> Mechanical Line Leak Detector. Model: /__;t) Zey,,�/ ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 'Tank Overfill/High-Level Sensor. Model: VIle Other(s ecif e ui ment ty2c and model it Section E on Pa e 2). ❑ Other(s ecif e ui ment ty2e and model in Section Fon Pa�e 2). Tank ID: Tank ID: g In-Tank Gauging Probe. Model: VIle ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 20 ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: V ❑ Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model:ZZ LJ 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/Fligh-Level Sensor. Model: ❑ Other(s ecif equipment ment t e and model in Section E on Pa e 2). ❑ Other(s ecif e ui ment tX2e w2 model in Section E on Page 2). Dispenser ID: I,sef Z Dispenser ID: 1514 ✓� _ ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dis enser Containment Float(s)and Chain(s). ADisgenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 19-13'' ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Q1 Shear Valve(s). Dispenser Containment Float(s and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser 1D: ❑ 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). _ *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 the report;(check all that�app: 4 System set-up Ala history rt Technician Name(print): eP 741 4-G�/91*5 Signature: re � , Certification No.: `Y �.�ie'GL License.No.: Cha Testing Company Name: P h01W No.:( 76 7 Site Address: ofTesting/Servicing: 7�Z�/' S— UN-036-1/4 Page I of 3 Rev.06/04/01 www.unidocs.org t