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ONIT NG SYSTEM CERTIFI ION For Cse By All Jurisdictions Within the State of Califon Authority Cited: Chapter 6.7, Health and Safeh� 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 In matin • Facility Name: Imo® Bldg. No.: Site Address: / 71 City: ®/ Zip: Contact Phone No.: Facility Contact Person: Make/Model of Monitoring Syst m: Date of Testing/Servicing: D. 1IlVCllLUL J' Vl Equipi—xiCIII ACJtGu/ vG�r aitt2u Check theappropriate boxes to indicates ecitic equipment ins ectcwac..�.��. n1. L" Tank ID: 11 In -Tank Gauging Probe. Model: Tank ID: In -Tank Gauging Probe. g g Model: fj Annular Space or Vault Sensor_ Model: ®' t® ❑ Annular Space or Vault Sensor. Model: Piping Sump /Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Detector_ Model: Model: X Mechanical Line Leak Detector. Model:L� Mechanical Line Leak ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: in Section E on Page 2). ❑ Other (specify equipment t e and model in Section E on Pa e 2). - ❑ Other (specify equipment t and model Tank ID: of IV In -Tank Gauging Probe. Model: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor_ Model: Piping Sump / Trench Sensor(s). Model: i �® ❑ Piping Sump / Trench Sensor(s)_ Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Model: Mechanical Line Leak Detector. Model:t ❑ Mechanical Line Leak Detector_ C3Electronic Line Leak Detector. Model: _ ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: L1 Tank Overfill /High -Level Sensor. Model: in Section E on Page 2). ❑ Other (s eci a ui in a and model in Section E on Pa e 2). ❑ Other (s ecif a ui ment t e and model Dispenser ID: ® L Cl Dispenser Containment Sensor(s). Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 19 Shear Valve(s)_ It Shear Valve(s). Dis Dispenser Containment ka lel Dispenser Containment Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Dispenser ID: ❑ 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 Containment Sensor(s). Model: Dispenser ID: Cl Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). - ❑Dis enser Containment Float(s) and Chain(s). ..A .7:.- �t tl.o £anility *If the facility contains more tanks or dispensers, copy this form- nc u 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 Piot Plar. showing the layout of monitoring eyuiprtent. For any equiptnent capable of generating such re orfs, I have also attached a copy of report; (checll all that y): System set-up Alarm history report Technician Name (print): ll,j ff✓1 Signature: Certification No.: icense. No.: i Testing Company Name: L/ Phone No.:( ) Sit / _ee 3 3 7 Site Address: Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification