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MONITORING SYSTEM CERTIFICATION For 1.4ve&.411 Jur•isclictionr Wiihin the State of*Ccrli1otvria rrthoritt%Cited: Chapter 6.7, Health erneSaky Code; C'holrter 16, Division 3, Title 23, California Code of '11 all ms This form must be used to document testing and servicing of monitoring equipment. A separate certification or re rt nutst be prepared for ach monitoring system control anel by the technician who performs the work. A copy of this form must e provided to the tank syste l owner/operator. The owner/operator must submit a copy of this form to the local agency regulatit UST systems within 30 days test date. A. General In • ation Facility Name: Bldg. o.: Site Address: City. Zip: Facility Contact Person: Contact Phone No.:( ) Make/Model of Monitoring Sys m: Date of Testing/ etvicing: B. Inventory of Equipmen Tested/Certified Check then ro riate boxes to indicates ific equipment inspected/serviced: Tank ID: Tank iD: ❑ In-Tank Gauging Probe. Mode ❑ In-Tank Ga/equipinent be. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Spult nsor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sumh ensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Swmp SModel: ❑ Mechanical Line Leak Detector. Model: O Mechanicalk Detector, Model: ❑ Electronic Line Leak Detector. ModeL• ❑ Electronic Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfi -Level Sensor. Model: ❑ Other(s cif e iui ment q` a and model in Section E n Page 2). ❑ Other(Spec' ment t e and model in Section E on Pae 2). Tank ID: Tank ID ❑ In-TankGauging Probe. Model: ❑ In-Tan Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Anny ar Space or Vault Sensor. Model: ❑ Piping Suntp/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Evil Sump Sensor(s). Model: El 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(s)ecif aqui ment t e and model in Section E on Pa e 2). ❑ Other(specify a ui ment t e and model in Section E on Pae 2). Dispenser ID: ispenser ID: ❑ Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ hear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ ' )eraser Containment Float(s)and Chain(s). Dispenser ID: Dispe er ID; ❑ Dispenser Containment Sensor(s). Model: ❑ Disp ser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Ive(s). ❑ Dis eraser Containment Float(s)and Chain(s). ❑ Dispense Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser C tainIlent Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s 19 ❑Dis eraser Containment Float(s)and Chain(s). ❑ Dis eraser Conta anent Floats)and Clrain(s). *I1'the facility contains more tanks or dis/tolis this form. LrchEde information for every t k and dispenser at the facility. C. Certification - I certify thment identified in this document was 'nspected/serviced in accordance with the manufacturers' guidelines. Attacertification is information (e.g. manufactm• •s' checklists) necessary to verify that this information is correct and a Plot g the layout of monitoring equipment. For y equipment capable of generating such reports,lhitvealsoattachediicoprt;(check alt that apply): ❑System set-u ❑ Alarm history report TechnicianName(print): FelixRamSignature: Certification No.: License.No.: ®TTL#08-i7 0 ICC#5273934-UT Testing Company Name: Phone No.:( Site Address: Date of Testis el'VECmLT: Page I of 3 03101 Monitoring System Certific ion D. Results of Testing ervicing