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AUG-24-2005 12:32 Service Station Systems 408 938 8888 P.03 MONITORING SYSTEM CERTIFICA,rION For Use By All Jurisdictions Within the Stole of California Authority Cited,,Chapter 6.7,Health and Safary 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_sepZrate certification or report must be p,,renared for each monitoring_a5tem 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 regulatirlg UST systems within 30 days of test date. A. GeneralInformatiol Facility Name: Bldg.No,: Site Address: City: 1 Z�LZip: Facility Contact Person:r� ,` �7; .., Contact Zone No,: _j_ _.__.. Make/Model of Monitoring System: Date of'Tosting/Servicing: B. Inventory of Equipment Tested/Certfied Check the aRpropriatc boxes to ind➢CAte pecitrc a i Ment ins ectcd/serviced; 'Tank ID: - _.. Tank TD- _. ❑ In-Tank Gauging Probe. Model: U In-Tank Gauging Probe. Model: N ❑ Annular Space or Vault Sensor. Model: .M Q Annular Space or Vault Sensor, Mndel: ❑ Piping Sump/Tmrioh Semor(s). ,ulnad: ❑ Piping Suinp I T.ca Cu ;,'(:). Model: ❑Fill Sump Sensor(s). Model, ❑ bill 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 I High-Level Sensor. Model: ❑ 'Tank Overfill/High-Levet Sensor. Model: v Other(ipecify a ui ment a and model in Section E on Page 2). U Other(specify a ui trent type and model in Section E on Pae 2). Tank ID: _ w� 'rank ID: -- Q In-Tank Gauging Probe. Model-. Cl In-Tank Gauging Probe. Modcl: , ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: O Piping Sump/Trench Sensor(s). Model: Q Fill Sump Sensor(s), Model: Q Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: ❑ Mccbanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: p Elcctronid bine Leak Detector, Model: w C1 Tank Overfill/High-Level Sensor. Model: _ V Tank Overfill IHigh-Level Sensor. Model: Q Other(s ci a ui mcnt t e and model in Section E on Pae 2 . D Other(s eci e i Ment !Land model in Section F on Pae 2 . Di ender ID: 6 r Dis enser ID: rp2ispenser Containment Sensor(s). Model:_ 2s'�� penser Coutaiamcnt Model: *Shear Valvo(s). 2 Shear Valve(s). © Dispenser Containment Ploat(s)and Chain(s). ❑ Dispenser Containment Floats and Chains , Fnwvalve(s). nserID;l,�,jlG DispenserID:_ ipenser Containment Sensor(s), Model ? ` El Dispenser Containment Scnsor(s). Model: ❑ Shear Valve(s). Q Dispenser Containment Floats and Chain(s), ❑ Dis enser Containment Float(s)and Chain(s). Di��ienser ID: Dispenser ID, penser Containment Scusor(s), Model:=n ❑ I1ispcnser Containment Sensor(s), Model Shear Valvc(s). ❑ Shear Valve(s). UDis enser Containment Floats and Chain(s), ❑ Dis enser Containment flouts and Chains. -if the facility contains more ranks 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. inanafa tuners' checklists) n cxaary to verity' that this Information is correct and a Plot Plan showing the layout of mtinitorinu equip nor any equip capable of generating such reports,I have also atta0ed a opy of the report;(check all that apple): y set- Al rstut y report Technician Narnc(print'): e�t� lJ� Signature Certification No.: Q�o "-U'' to b ...... License.No.: Testing Company Name .-S _ Phone No.:(-10y )_Ca ".,�� I w :1 Site Address: __.�........,... Date of Tcsting/Scrvicing: Page I of 3 03/01 Monitoring System Certification D, Results of Testing/Servicing