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MONIARING SYSTEM CERTIF ATION r' 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 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 perfoims the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy ®f this form to the local agency regulating UST systems within 30 days of test date. A. General Information _ p Facility Name: (/I�� $1 b � v Bldg.No.: Site Address: SJ fit, ,/�R�JY�r7 City: �U 4'.,It T Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: g 3{ !1 Date of Testing/Servicing: '1/ B. Inventory of Equipment Tested/Certified 8 q sd t GZ�aScs Check the appropriate boxes to indicate specific equipment inspected/serviced: Ta ID: _ Ta ID: l CV�n-Tank Gauging Probe. Model:. /V A;"Y E Tank Gauging Probe. Model: /`1! ` V)Innular Space or Vault Sensor. Model: [� ular Space or Vault Sensor. Model: 3 v 'CVPiping Sump/Trench Sensor(s). Model: a iping Sump/Trench Sensor(s). Model: C2 d ❑ ill Sump Sensor(s). Model: ❑��F'll Sump Sensor(s). Model: fff Mechanical Line Leak Detector. Model:�/ .,Q c,�, C Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/Hick-ECve'f'.'ef-'� izsott ModelPlrt/(��c1 F"Tank Overfill/Hi - eve Seenns7rr Model: .60t,1-61 X,�' ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type 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(specify equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). Di enser ID: z Diss enser ID: V8 spenser Containment ensor(s). Model: 04>, fc��ispenser Containment Sensor(s). Model: Lf 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). ❑ 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). ❑ 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 monitor!5g equipm n. For any equiipp�nt capable of generating such reports,I have also attached a copy of the report;(check all that ystem set-up l�Alarm history report Technician Name(print):_Tom Corcoran Signature: Certification No.: 661-7 J> License.No.: S Testing Company Name: Triangle Environmental, Inc. Phone No.:(818)840 7020 Site Address: IRIANGLE ENVIRONMENTAL, INC. Date of Testing/Servicing: _ 2525 W. BURBANK BLVD. BURBANK (', -,s r. non2 Pagel of 03/01