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;L) MONITORING SYSTEM CERTIFICATION DEC 3 0 2004 For Use By All Jurisdictions Within the State of California ENVR 1I'tL : i i1EALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16,Division 3, Title 23, California Code SES 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: '--`'` EL..•O-C.S y Bldg.No.: Site Address UCity.,Tr'-0)t\1 Facility Contact Person{`�\A-1( L,Pr C� P, Contact Phone No.: Make/Model of Monitoring System:v 5u Date of Testing/Seryicing: v B. Inventory of Equipment Tested/Certified Check the 2ppropriate boxes to indicates ecific equipment inspected/serviced: Tank ID: c'�v'`��fV.:.y Tank ID: �- (� t �t- -4 1n=Tank Gauging Probe. Mude1 Q 3�0_t t7'i �I In Tank Gauging Probe. Model:P (-1-3'_%,0 `-1U'1 6 Annular Space or Vault Sensor. Model: (+Annular Space or Vault Sensor. Model:l"1 M--36kx 30'� Piping Sump/Trench Sensor(s). Model: C% 3_Xz--1C9N 11 Piping Sump/Trench Sensor(s). Model: e.l..31'2-_Z� Fill Sump Sensor(s). Model:7�•-. 41-'��'2.--u 0 Fill Sump Sensor(s). Model:r7%vt-3P'_1 -Zu ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: t'LLY 4 *ijd Electronic Line Leak Detector. Model: JY It fN ID Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecif equipment t e and model in Section L- on Pa e 2). 1 ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: JJw h►�1 Tank ID: ❑ In-Tank Gauging Probe. Model:. LO --LO'"1 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 4,- ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model:14LI OR ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model:`7S L' 7 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: l Electronic Line Leak Detector. Model: �yl 1p LJ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify a ui ment type and model in Section E on Page 2). Dispenser ID: t Dispenser ID: )r. u C� Dispenser Cot ainment Sensor(s). Modef7!S �4 GUDispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Floats and Chains). Dispenser ID: L Dispenser rD: , 0 Dispenser Conta nment Sensor(s). Model:7 Dispenser Containment Sensor(s). Model:ZC1, ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: Q Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats and Chains . '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 equipment. For any equipment capable of generating such reports,I have also attached a copy of the rpport; (checkqU that apply): ❑System set-up ❑.Alarm history report Technician Name(print):f" .-C' � g tr..`{= L� Signature: Certification No.: License.No.: Testing Company Nam(e�,'��`�� <c f1 ,ni��"� Phone No.:( ,!C;P) L( Site Address: J.:l Date of Testing/Servicing:L k� UN-036-1/4 Page I of 3 Rev.06/04/01 www.unidocs.org