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r W11/12/2003 11:10„ _ 9163712 0 BZSERVSTAMAINT PAGE 02 MONITORING SYSTE CERTIFICATION For Use By All Jurisdicdot*Mthin the State of California Authoruy Cited:Chapter B 7,Health and Safety Code;Ch*'fer 16,Divisiori 3, 77tle 23, California Coda of Regulations This form must be used to document testing and servicing of monitoring equipment.A fiagaM certification or report must be papered fff) rWAZ9fijrDAUjv11jij&M eantrol palled by the.tcelmiaian who Wrforms the work. A copy of this form must be provided to the tank system oWnWoperator. The owner/operator must submit a copy.of this form to the local agency regulating t',77ST systema within 30 days of test date. A. General Wo ti ... Facility Na : Bldg.No, Nam: Site Address: City. C p ---..-........_.. Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: 2 k12 Date of Testing/Servicing:RJ B. inventory of Equipment Tested/CertMed cbea then to bases to indicate m4cifle equil t!ns rT lD: Tants ID: In.i nk Gauging Probe. Model: ❑ In-Tank Gap"Probe. Model: jis alar Space or"vault Sensor. Model: ❑Annular Space or Vault Senaor. Model: ping Sump/ Seatsor(s). Model: O Piping Sump/Trench Sansor(s), Model: 0 Fill Sump s). Model: f ❑Frill Sump Sensor(s). Model: 0 Mechanical Lina Leak Dourtot. Model: Q Mechanical tine LAmk Detector. Model. U al L;M Leak Detector. Model: ' Q Electronic Line Leak r. Model: Tank OvaU/ Leval.Sensor. Model: ❑Tank OvaM I W*Level Sensor. Model: (3 O t M and model in Section E on Pae 0 Other 8 equipment t and model in tion 15 on Page 2). Tank dam: Tank UX ❑ In-Panic Gauging Probe. Model: U.In-Tank GW91mg Probe. Model: ❑ Annular Space or Vault Sensor. Modcl. ❑ Anular Space or Vault Sensor. Model: Q'Piping Sump I Trench Sensor(.). Model: 13 piping Sung/Trench Sonsor(s). Model: 0 Pill Stutz Scmw(a). Model: Q Fill Sump Sensor(a). Model: ❑ Mechaaied Une.Leak Detector. Model:_ ❑Mechanical Lina Leede.Detector. .Model: Q Electronic Lim Leak Detector. Model: a Electronic Lim Look Detector. Model: 13 Tank Ovum/Ifigh-Level Sons". Model: ❑Tank OvetFU/HWL.evel Sensor. Model: O Others ui mens and model in Section E of Pate 2. ❑Othsz s i t t and model in Section E on Pa e 2. . Dispenser ID: ID: D Dispenser COnt4runent s). Model:a Q Dispeum Containincut Samr(s). Modal: _ ❑ Shesr Valvo(s). ❑ Shear Vatve(8). ® MOM Containment Flo&tW and t q. ❑ Rim=Containment s and Chains. Dtsperaer IIlDiqpensw ID: ❑ Dispenser Contaitr1WPt Sensor(s). Model: O Dispenser Containment Sensor(s). Model• ® Sbcar Valve(s). 0 Shear Vaive(s). p b er Containment Floats and Ckrain s . Q Dls Containment Flo L%2 and Chale s. pispestses JADispenser ID: Q Dispenser Contairuncast Sensor(s). Model: Q Diapaaw Containment Sensor(s). Model: (3 Shear Valve(s). ❑'Shear Vaive(a). UDisoff COnWolnent drloa s and Chain(s). ❑ DbMecr Containment FI!Ws and Chaff s. •If the facility contains mote tanks or dispensers,copy this form. Include b6nnation fa every tank and dispenser at the facility. C. Ce cation•I certify that the equlpanent identified in this t was InspecteWserviced! elf/servicedccordance with the manufacturers' guldelipm ,Attached to this C ortiflestion is information(a$, n*n ers° checklists) to verify th8t this information Is correct and a Plot Plan showing the layout of monitoring a ulp"001. For my etibl generating ouch reports,I have also altacbed a copy of the repo:{chsek all stbill set-up m eport, Technician Name(print): ei � l .,� Signature: Certification No,: — License.No.. .–J4,72 / 5—q Testing Company Name: Phone No.: > .17 1 .� Site Address: IAIDate of Testing/Servicing: Page(1 of 3 03/01 Monitociag System Certification