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Nov 04 10 07:33a Elite TV Contactors 120946'-5342 p.2 Appendix Vl (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.ciov.) MONITORING SYSTEMA 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 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 Information Facility Name: //SS z(,lref�1�% Bldg. No.: Site Address: ` i� IC City:L / Ly) Zip:/.7 Facility Contact Person: Contact Phone No.: t2 , ��/ 3 77 Make/Model of Monitoring System: 1 Date of Testing/Seryicing: / _'I r� Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: sv� 7 141Tank ID: C;1.J L_ In -Tank Gauging Probe. Model: ")0C' a in -Tank Gauging robe. Mode:- C Annular Space or Vault Sensor. Model: ' 0 -. '�. C Annular Space or Vault Sensor. Mode: C Piping Sump I Trench Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: C Fill Sump Sensor(s). Model: '16 - Q .7 0 Fill Sump Sensor(s). Model: C Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: C Electronic Line Leak Detector. Model: i -LQ 3 Electronic Line Leak Detector. Model: C Tank Overfill / High -Level Sensor, Madel: 3 Tank Overfill / High -Level Sensor. Model: C Other (specify equipment t e and model in Section E on Page 21. 7 Other (s2ecify a ui ment tXpe and model in Section E on Pae 2). Tank ID: Tank ID: - in -Tank Gauging Probe. Model: n In -Tank Gauging Probe. Model: _ Annular Space or Vault Sensor. Model: u Annular Space or Vault Sensor. Model: - Piping Sump / Trench Sensor(s). Model: C Piping Sump / Trench Sensor(s). Model: C Fill Sump Sensor(s). Model: C Fill Sump Sensor(s). Model: C Mechanical Line Leak Detector. Model: C Mechanical Line Leak Detector- Model: C Electronic Line Leak Detector. Model: G Electronic Line Leak Detector. Model: C Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: C Others eci equi ment tyce and model in Section E on Page 2). ❑ Other (se2cify equipment t e and model in Section E on Paqe 2 . Dispenser ID:_ '-7 'Gi Dispenser ID: p� 1'c�LS Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: ( Shear Valve(s). ' ( Shear Valve(s). C Dis =ser Containment Float s) and Chain sl. 0 Dis enser Containment Floats and Chain(s). DispenserlD: DispenserlD: C Dispenser Containment Sensor(s). �_ Model: Dispenser Containment Sensor(s). model:1763 _ pL Shear Valve(s). 171; Shear Valve(s). _ Dispenser Containment Floats and Chain(s . 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: - Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: _ Shear Valve(s). a Shear Valve(s). C Dispenser Containment Floats and Chains u 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 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 verity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): C System set-up D Alarm history report Technician Name (print) L 41r/?.� _ _ ,^<- Signature: a Certification No.: ,J _ ,o X14'`" L l f' Vicense. No.: (�t^.(?I ,6 i 4 13C' - G H (I Z Testing Company Name: _ 1 T f �YGt t� Phone�No.. -C, ( L C�?j'�/ Testing Company Address: 1 ` i } .1, Y Gia Date of Testing/Servicing: It)(g/ C2 0 40 Monitoring System Certification Page 7 of 4 12107 2/21/07