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MONITORING SYSTEM CERTIFICATION MAY 3 12002 For Use By All Jurisdictions Within the State of California NT HEALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code "694ERVICES 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. GeneralInformatiort-6 Facility Name: Site Address: 130 5. W11 -M WV City: �_:� Facility Contact Person: C6WWXtC Contact Phone No.: Make/Model of Monitoring System: eman �0(",dv Date of Testing/Servicing: 14 Bldg. No.: Zip: _ B. Inventory of Equipment Tested/Certified Check the anornnriate boxes to indicate specific equipment insnected/serviced: Tank ID: Tank ID: Mb ❑ In -Tank Gauging robe. Model: O In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: LS'_) �R Annular Space or Vault Sensor. Model: U3-1 Piping Sump / Trench Sensor(s). Model: 5''S 'ig Piping Sump / Trench Sensor(s). Model: Cl Fill Sump Sensor(s). O Mechanical Line Leak Detector. Model: Model: ❑�Fill Sump Sensor(s). .4a`y Mechanical Line Leak Detector. Model: Model: .5" P>Q\j JW Electronic Line Leak Detector. Model: cer ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: O Other (specify equipment tv a and model in Section E on Page 2). ❑ Other (specify equipment ty e and model in Section E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gaugi g Probe. Model: C1In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: S•1 ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: C'j ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LZIWIX ❑ Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecify a ui ment ty e and model in Section E on Page 2). ❑ Other (specify equipment ty a and model in Section E on Page 2). Dispenser ID: i_Z Dispenser ID: 3"4 X Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model:'�Zl2'CU 1 ❑ Shear Valve(s). ❑ Shear Valve(s). O Dispenser Containment Float(s) and Chain(s). O Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: -1'g X Dispenser Containment Sensor(s). Model: 3U _1 -iM ❑ Dispenser Containment Sensor(s). ModeJ:'33L7LA?_-00N ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: — to Dispenser ID: 11—g O Dispenser Containment Scnsor(s). Model: 107-kZ —00 ❑ Dispenser Containment Sensor(s). Mode1:*5-,AX 7Z--QUl O Shear Valve(s). ❑ Shear Valve(s). ODis 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 dispenser at the facility. C. Certification - I certify that the equipment identiried 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 equipment. For any equipment capable of generating such re I ve also attached a copy of the report; (check all that apply): C3 System set-up CD Alarm history repot Technician Name (print): 'msr F nontana Signature: Certification No.: Cc�_tk�t) License. No.: Testing Company Name: Scott Co. Of California Phone No.:( 51(1 ) R95-2333 x -.RS Site Address: Mab Date of Testing/Servicing: _/_/_ Page I of 3 03/01 Monitoring System Certification