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f MONITORING SYSTEM CERTIFICATION AUG 1 6 2007 ` For Use By All Jurisdictions Within the Stare of California �I i Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Cb, �R �g ¢Nj{q' ALTH This form must be used to document testing and servicing of monitoring equip ment.A s w1 IttiV►t Fs g Sep rate 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 Inform ation Facility Name: Bldg.No.: Site Address; City: 1 t P: Facility Contact Person: Contact Phone No.: t_Cio J a Make/Model of Monitoring System: Date of Testing/Servicing. B. Inventory of Equipment Tested/Certified Check the agprogriate boxes to mndicat sPeeffic eQuipment ins ected/serviced Tank ID: �l Tank ID: t ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. ModerIR435a`4T1 Annular Space or Vault Sensor. Model'Kt4�fs1-'-1Q1 Piping Sump/.Trench Sensor(s). Model` Piping Sump/Trench Sensor(s). Model- b`ro- �k� ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model: t{ )K Mechanical Line Leak Detector. Model:SI I•w 6-C&InnLo ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specia equipment type and model in Section E on Page 2). ❑ Other s eci' 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(spec" ui meat t and model in Section E on Paoe 2). ❑ Other(sEecify equipment type and model in Section E on Pa e 2). Dispenser ID: - Dispenser ID: U 41 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model:'1G43fGt1?JUp ❑ Shear Valve(s)" ❑ Shear Valve(s). ❑ Dispenser Containment Flow(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser Dispenser ID:`1 Dispenser Containment Sensor(s). Mode r- r� p(�Dispenser Containment Sensor(s). Model:-- El Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floa[(s)and Chain(s). ❑ Dispenser Containment Flow(s)and Chain(s), Dispenser ID: Dispenser ID: ❑ Dispenser Conta,nment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Flog[(s)and Chain(s). ❑ Dispenser Containment Floa[(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 ins pected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify correct and a Plot Plan showing the layout of monitoring pment. For any equipmentthat this information is capable of enerati such reports,I have also attached a copy of the report;(check al that apply); System set-up o Technician Name(print Signatur ort Cenification No.:' -UT License.No.: S-�(�� (� Testing Company Name: QST Phone No.: Site Address: • g/ g �/ �u /M Date of Testis Servicin Page 1 of 3 Monitoring System Certification 03101