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. r MONITORING SYSTEM CERTIFICATION For -Use By All Jurisdictions Within the State of California A whorin, Cited: Chapter 6. %, Health and Safer), 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 Informatio Facility Name: 1 Bldg. No.: Site Address: r City: , Zip: Facility Contact Person: '-/ v%tr Contact Phone No.: ( )T72- Mike/Model T tiMike/Model of Monitoring System: AL5 `" ,a Date of Testing/Servicing: / ./ B. Inventory of Equipment Tested/Certified ., i..,-._ •.. _AC- -Ar" _-*--1 i nPri Pf1kPrArPft' Tank ID: Tank ID: In -Tank Gauging Probe. Mod el:,• _ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Mode 1511 Annular Spaee'or Vault Sensor. Model: Piping Sump / Trench Sensor(s). M( X Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s)'. Model: 5d Mechanical Line Leak Detector. Model: K Mechanical Line Leak Detector. Model: 1- e, ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line.Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equi went t and model in Section E on Pae 2). ❑ Other (s ifv eaui ment DM and model in Section E on Page 2). T nk 1D: In -Tank Gauging Probe. Model: Tank ID: In -Tank Gauging Pro e. Model: Annular Space or Vault -Sensor. Model: log Annular Space or Vault Sensor. Piping Sump / Trench Sensor(s). Mode]: Model: Piping Sump /Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Of Mechanical Line Leak Detector. Model: Model: ®1 ❑ Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: Model: C' ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / Nigh -Level Sensor. Model: ❑ Tank Overfill / Nigh -Level Sensor. Model: ❑ Other (s ify equi ment type and model in Section E on Pa e 2). ❑Other (s cifY equipment tv and mode] in Section E on Page 2). Dispenser ID: I Dispenser ID: 7t ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). t Shear Valve(s). I Dis enser Containment Float(s) and Chain(s). Dis nser Containment Float(s) and Chain(s). Dispenser ID: ' Dispenser ID: L ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 5( Shear Valve(s). 4 Shear Valve(s). Dis enser Co ainment Float(s) and Chain(s). 4 DisLxnser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ispenser 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 tot every tank and dispenser at the lactuty. C. CertlfiCatlon - 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' checklist) 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 re ort:(check all that apply): ts System set-up Alarm history re ort Technician Name (print): n 9 it cl Signature: Certification No.: 005 1 License. No.: Testing Company Name: `C` y' Phone No j Site Address: i f '� Date of Testing/Servicing: Page 1 of 3 03/03 Monitoring System Certification