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MONITORING SYSTEM CERTIFICATION 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 Facility Name: Bldg.No.: Site Address: Z City: � Zip: Facility Contact Person: Contact Phon No.:( ) Make/Model of Monitoring System: �f1�' G71',6 Mr—0 Date of Testing/Servicing: G /1jL/ !'3 B. Inventory of Equipment Tested/Certified Check the apEroeriate boxes to indicates ecific ui ment ins ted/serviced: Ta ID: Ta ID: Tank Gauging Probe. Model: !' - ' ,jn Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: � U Mhular Space or Vault Sensor. Model: -,lei� Piping Sump/Trench Sensor(s). Model: Oe ("Piping Sump/Trench Sensor(s). Model 49. ❑ dill Sump Sensor(s). Model: �,a' ❑�ump Sensor(s). Model: Mechanical Line Leak Detector. Model: FAX Z Mechanical Line Leak Detector. Model: �X ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detectors _�jpdel: Er ffank Overfill/Higl-teve Model: ! �h/(,j J"(-' (@">�ank Overfill/Ii refs oi. Model: ra r✓ ❑ Other(specify ui ment and model in Section E on Page 2). ❑ Other(specify ui ment type and model in Section E on Pae 2). Tagk ID: Tank ID: p/ Tank Gauging Probe. Model: ^- L3 In-Tank Gauging Probe. Model: LP's ranular Space or Vault Sensor. Model: 1_ � ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ' r7 ❑ Piping Sump/Trench Sensor(s). Model: ❑ 1 Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: IT Mechanical Line Leak Detector. Model: L1) a cfv-J ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: i nk Overfill/�sor. Model:Q OAo el 541 ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(speciLy 2quiement tyeE and odel in Section E on Pae 2). ❑ Other(specify ui ment typS and model in Section E on Pa Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor( Model- Lispenser Containment Sensor(s). Model: 32''gear Valve(s). SI ar Valve(s). is nser Containment Float(s)and Chain(s). VM nser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Cl 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). ODimenser Containment Float(s)and Chain(s). ❑ Dis enser 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 Lreport__�eneratieports.I have also attached a copy of the report heck all that apply): &i5 stem set-up C� A ory Technician Name(print): i - C 0 ft G-"`1 Signature: ' Certification No.: ENVIRONMENTAL, INCO ,-7Si cense.No.: Testing Company 2525 W. BURBANK BLVD.U 15ANK, CA _2a-02Phone No.:�.�� o y o' 70;-0 Site Address: U I� Date of Testing/Servicing: C' F � _ Page 1 of 3 0- 111 Monitoring System Certification