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0 • MONITORING SYSTEM CERTIFICATI®N 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 of Regulations e arate ust be repared This form must be used to document testing and technician who performservicing of monitoring the work. Auipment, A scopy of hicertification form must be provided t pthe tank for each monitoring system control panel y of this form to the local agency regulating UST systems within 30 system owner/operator. The owner/operator must submit a copy days of test date. A. General Inform tion Bldg. No.: ` Facility Name: 4,/4- Zip: /4' �_city: Site Address: —!u Contact Phone No.: C__ _ ) Facility Contact Person: Date of Testing/Servicing: Make/Model of Monitoring System: I j' B. Inventory of Equipment Tested/Certifse—ne�cted/scrvtced: Tank ID: ❑ In -Tank Gauging Probe. Model: /!� ❑ Annular Space or Vault Sensor. Model: _ ❑ Piping Sump / Trench Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model:_ ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: _ ❑ Other s ecif a ui Ment t e and model in Sc k ID:ir- �.— C] In -Tank Gauging Probe. ❑ Electronic Line Leak Detector. / High -Level Sensor. ❑ Annular Space or Vault Sensor. Model: _ ❑ Piping Sump / Trench Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: _ ❑ Mechanical Line Leak Detector Model: _ ❑ Electronic Line Leak Detector. Model- ❑ Tank Overfill / High -Level Sensor. Model: _ ❑ Other (s ecif a in merit type and model in S i Dispenser ID: El Dispenser Containment Sensor(s). Model: _ U --Shear Valve(s). ❑ Mechanical Line Leak Detector. Dispenser ID: U -Dispenser Containmen Sensor(s), Model: D -Shear Valve(s). 13 Dispenser Containment Float(s) and Chain(: Dispenser ID: j • ---- -- -- zi-Dispenser Containment Sensor(s). Model: WShear Valve(s). Dispenser ID: I -Model: 3 i q " ` "'.e, �=� f Q"Dispenser Containment Sensor(s). (-Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: �Tl is • ❑ Dispenser Containment Sensor(s). Model: `�- ❑ Shear Valve(s), and Chain(s). ❑ Dig enser Containment Floa(s) Dispenser ID: /�� 6• _ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). O Dis enser Containment Floats and Chain(s). *If the facility contains more tanks or dispensers, copy mis form. Include information for every tank and dispenser at the facility. viced ance the C. Certification - I certify that t the Certification en informatioed n (thisg. manucu facturers'ncheckl ts)rnecessary torverify thalt this informationis guidelines. Attached toent correct and a Plot Plan showing the layout of monitoring equipment, q Symet, set-up y equipm ®Alarm capable istory rgeneratingrt such reports, I have also attached a copy of the report"+� ,(check all that app i Signature: Technician Name (print): License. No.: Certification No.: Z �Z Phone Noj—) .:( g� Testing Company Name:a' Date of Testing/Servicing: -- — Site Address: 03/01 Page I of 3 Monitoring System Certification Tank ID: C3In-Tank Gauging Probe. ModeL' !; ' `7l, Model: / } �{ ei ❑ Annular Space or Vault Sensor. (; j Model: )` i�= ❑ Piping Sump / Trench Sensor(s). ----- Model: ❑ FiII Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: 7 t!✓ fi„ ,, 5 ❑ Electronic Line Leak Detector. / High -Level Sensor. Model: ❑ Tank Overfill ❑Other (s ec' a ui merit t e and model in Section E on Pa&c 2). on E on Pa e 2 . FF � : V _ Tank ID: 7—" ❑ In -Tank Gauging Probe. ode/ ` /-j `�_�.—` - — , 1 - Model �, ti l ❑ Annular Space or Vault Sensor. Sump / Trench Sensor(s). Model =(- ❑ Piping ❑ Fill Sump Sensor(s). `z Model:- ❑ Mechanical Line Leak Detector. Model - a.-: ModeL• ,3 �— ❑ Electronic Line Leak Detector. �— ❑ Tank Overfill / High -Level Sensor. Model: in Section E on Page 2 . ion E on Page 2 . Q3 Other s ecif a ui Ment t nd e amodel Dispenser ID: I -Model: 3 i q " ` "'.e, �=� f Q"Dispenser Containment Sensor(s). (-Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: �Tl is • ❑ Dispenser Containment Sensor(s). Model: `�- ❑ Shear Valve(s), and Chain(s). ❑ Dig enser Containment Floa(s) Dispenser ID: /�� 6• _ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). O Dis enser Containment Floats and Chain(s). *If the facility contains more tanks or dispensers, copy mis form. Include information for every tank and dispenser at the facility. viced ance the C. Certification - I certify that t the Certification en informatioed n (thisg. manucu facturers'ncheckl ts)rnecessary torverify thalt this informationis guidelines. Attached toent correct and a Plot Plan showing the layout of monitoring equipment, q Symet, set-up y equipm ®Alarm capable istory rgeneratingrt such reports, I have also attached a copy of the report"+� ,(check all that app i Signature: Technician Name (print): License. No.: Certification No.: Z �Z Phone Noj—) .:( g� Testing Company Name:a' Date of Testing/Servicing: -- — Site Address: 03/01 Page I of 3 Monitoring System Certification