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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7,Health and Safety 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 o ire port must beprepared hnician who performs the work. A copy of this form must be provided to the tank for each monitotine system control panel by the tec copy of this form to the local agency regulating UST systems within 30 system owner/operator. The owner/operator must submit a days of test date. A. General Information � � Bldg.No.: Facility Name: SL Site Address: � City: gip' ` Contact Phone No.: ?y Facility Contact Person: 3 7 Make/Model of Monitoring System ,.t�i�c -'+--��'°' —'S U Date of Testing/Servicing: A B. Inventory of Equipment Tested/Certifted Check the appropriate boxes to indicatespecific ul ment ins ected/serviced: Tank ID: Tank ID: � ❑ In-Tank Ganging Probe. Model: Ohi-Tank Gauging Probe. Model: 9y„ D-- pit Annular Space or Vault Sensor. ModeL'�py7DP ..a/p'9_ Annular Space or Vault Sensor. Model: t�y]t, Piping Sump/Trench Sensor(s). Model: 1-1 7O Piping Sump/Trench Sensor(s). Model•? Fill Sump Seasor(s). Model: Fill Sump Sensor(s). Model:�-- Mechanical Line Leak Detector. Model: 111A' I—t7 'Zr:YJfl Mechanical Line Leak Detector. Model�,� l•^r I '7[Y3fy Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: E3 Tank Overfill/High-Level Sensor. Model: LJ Tank Overfill/High-Level Sensor. Model: ❑ Other s i e ' ment type and model in Section E on Page 2). ❑ Other(speci ui meat and model in Section E on Pa a 2). Tank ID: P_ Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ' `Anular Space or Vault Sensor. Model: ` Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: t ' 2 rJ%- ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). +�` ' Model: L3 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: C1Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: L3 Tank Overfill/High-Level Sensor. Model: Q Tank Ove ll/High-Level Sensor. Model: El Other(s ui ment a and model in Section E on Pae 2). L3 other(s ci ui went t e and model in Section E on Pa a 2). Dis user ID: I- T �Diry ypcnser ID: Dispenser Containment Sensor(s). Model:7f v 3 Fir ZD s' yr/`Dispenser Containment Seasor(s). Model: 99 Shear Valve(s). /CKSheaz Valve(ar ❑ Dis enser Containment Float(s)and Chain(s). /❑ Dis user Containment Float(s)and Chain s). ID: tx_= / ' peruserID: '- Dispenser Containment Sensor(s). Model: '79 dTB0' ?cis Dispenser Containment Sensor(s). Model::'7P r17.PlJ•ZJrS Shear Valve(s). Shen Valve(s). 0 Dis enact Containment Float s)and Chains . Dis enser Containment Ploat s and Chains. Dispenser ID: Dispenser ID: E3 Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear i ODis user Containment Float(s and Chain s). ❑ Dis user ser Containment Float(s)and Chainci *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 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 Plot Plan showing the layout of monitoring egpipmenL For any a pment capable of generating such reports,I have also attached a copy of the rep ;(check all rl�gt apply)i CfSyslem set-up lar `to (report Technician Name(print): � llz� /i7�^ tom— Signature: Certification No.: i� 77__� -7 7 �l License.No.: y q� - r ,.v, o r.�,�! Testing Company Name: r Phone Date of Testing/Servicing: Site Address: Page 1 of 3 03101 Monitoring System Certification