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MONIT RING SYSTEM CE T'IR TION Fo, _ , •e By .-ill Jur•isdiclkons I1'ilhin the Sliile of Calkfo, a Aulhorily Cileck: Chapter 6.7, Health and SgIL,hy Coele; Chapter 16, Division 3, Title 23, California Cocke gf'Requlalions 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 3t�56ys of test date. A. Genera Facility Name Site Address: Facility Contact Person: Contact Phone No.: g. No. Zip: Make/Model of Monitoring System:�� "t —' "t / ,� , Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified p o i re a k Check the annronriate boxes to indicate specific eauinment insnected/servired- Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ¢ ❑ Piping Sump / Trench Sensor(s). Model: KA -' ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Tank lD:a) / ! Tank ID: ❑ In -Tank Gauging Probe. Model: 4�, ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ 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). Model: ❑ 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 equipment ty a and model in Section E on Page 2). ❑ Other (seeciLy equipment t e and model in Section E on Pa a 2). Dispenser ID: I �— --.2, Dispenser [D: T ❑ Dispenser Containment Sensor(s). Model: Ig 0AII ❑ Dispenser Containment Sensor(s). Model: Lj D ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 67 Dispenser ID: ? I' q— ❑ Dispenser Containment Sensor(s). Model: ❑ 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). ❑Dis enser 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 for every tank` and dispenwr at the facility. C. Certification - I certify that the equipment identified thisl oXnien-i" was inspected/se ,iced in acco-rda&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 of generating such reports, l have also attack ed a copy of the report; (clheck all that apply'): ❑ S stefnset u ,® Alarfn irt'story-report Technician Name (print): /- /-Y//p % / 1',Z'e 'A -a-7 Signature: Certification No.: License. No.: f /6(23 Testing Com an Name ,' " 4 l °`- Phone No (r:;! Site Address: �4 to E Z' tt 0. Date of Testing/Servicing: J I / Page I of 3- P Monitoring System Certification D. Results of Testing/Servicing 03/01