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b � MONITORING SYSTEM CERT CATION 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 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 systems within 30 = days of test date. A. General Information j� a ycl 7 Facility Name: G/��1?�-C(/� 1I�� Bldg.No.: Site Address: ��( tc• /Y�ovH/Y�.�eR /1 Qwu City: y 0 C-XI0 Zip. Facility Contact Person: Contact Phone No.:(_) Make/Model of Monitoring System: 3 S�� Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific a ui ment ins cted/serviced: Tank ID: Tank]D: ''in-Tank Gauging Probe. Model: M S 8n-Tank Gauging Probe. Model: A4 Aqr I ��nular Space or Vault Sensor. Model: l"An lar Space or Vault Sensor. Model: B P'ping Sump/Trench Sensor(s). Model: .� U-111ping Sump/Trench Sensor(s). Model-. OSr F11 Sump Sensor(s). Model: E3Filpump Sensor(s). Model: Mechanical Line Leak Detector. Model: I echanicai Line Leak Detector. Model: . Electronic Line Leak Detector. Model: _ ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/HiVaped. Model: OPW 613a" ❑ Tank Overfill/High-Level Sensor. Model: d PW 6 1.9 ❑ Other(specify equiptAent type and model in Section E on P!&e 2). ❑ Other(specify ui ment=and inodel in Section E on Pae 2). T ID: Tank ID: 5-v -Tank Gauging Probe. Model: M A ^/ W In-Tank Gauging Probe. Model: Anular Space or Vault Sensor. Model: 'bo 2 Cannular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: O*iping Sump/Trench Sensor(s). Model: o ❑—1FF'll Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: tYMechanical Line Leak Detector. Model: L,,>!J_sr<JQ NeMechanical Line Leak Detector. Model: 5c1 eP /h !7 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model:d 2 t._t6 o 56 ❑ Tank Overfill/High-Level Sensor. Model:'/)O W ❑ Others ui ment!M and model in Section E on Page 2). ❑ Other(specify ui ment typeAnA model in Section E on Dispenser ID: / Dispenses ID: 3 ❑ Dispenser Containment S sor(s). Model: ❑ user Containment S nsor(s). Model: ' hear Valve(s). ear Valve(s). s nser Containment Float and Chain(s). Dis ser Containment Fl t(s)and Chains. 411 Dispenser ID• Dispenser ID• 7/6 ; O Qispenser Containment nsor(s). Model: rea nser Containme Sensor(s). Model: (�' Valve(s). Valve(s).Drs nser Containment Float(s)and ain(s). user Containment FI t s and Chain(s). ispenser ID• Dispenser / . _ ❑ Dispenser Containment Sensoo Model: s ser Containme Sensor(s). Model: .0 4y. S :Valye(s). ka 9gear valve(s). 2012jensff&ntainment Floats and Chain(s). I CYDispenser Containment Float(s)and Chains). *It 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 inthis docu ent was inspected/se ced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. ufacturers' checkli necessary to verify that s information is correct and a R 2im showing the layout of monitoring t. For any equip t capable of generatin reports,I have also attached a copy .4he report• check all that apply): ystem set-up ory repo Technician Name(punt): 7 C o 0-Ga AA Signature: Certification No.: TRIANGLE ENVIRONMENTAL, INCb�7S License.No.: Oo2 `/'�o2 l 2525 W. BURBANK BLVU Testing Company O Phone No.: Site Address: tS U n ® Date of Testing/Servicing: //�� Page 1 of 3 03!01 Monitoring System Certification a