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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 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. *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 generatin reports, I have also attached a copy of the reportL(heck all that apply): ❑ System set-up ❑ A or, repot Technician Name (print): f - C o f==Gv2A "� Signature: Certification No.: TRIANGLE ENVIRONMENTAL, INCe;w License. No.: 09 Testing Company I2��}t�• . _ . Phone No.:( Site Address: 61 ° CA Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification A. General Information S' 1 %' Facility Name: v1 I` Bldg. No.: Site Address: �t1'1 /Yll City: J cf Zip: Facility Contact Person: Contact Phone No.: O n _ Make/Model of Monitoring System: C Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified r3g-,� df 7d .S—� v Check the appropriate boxes to indicate sRESific equipment ins ectedtserviced: T4c IIT 'nk ID: E'! Gauging Probe. Model: All ' I— pular Space or Vault Sensor. Model: ank Gauging Probe. Model: �/nnu ar Space or Vault Sensor. Model: Piping Sump /Trench Sensor(s). Model 021 g Sump /Trench Sensor(s). Model: ❑ Fdl Sump Sensor(s). Model: ❑ I Sump Sensor(s). Model: mechanical Line Leak Detector. Model: 1�chanical Line Leak Detector. Model: — ❑ Ylectronic Line Leak Detector. Model: L] ,Flectronic Line Leak Detector. Model: Tank Overfill / Hig rsor. Model: P✓v 6I S74 Tank Overfill / High r. Model: ❑ Other (s ify EquiLiZent t3W and model in Section E on P!&e 2). ❑ Other (specify ui ment type and model in Section E on Page 2). T ID: Tank ID: k Gauging Probe. Model: Z- ❑ In -Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: ? ❑ Annular Space or Vault Sensor. Model: Piping Sump /Trench Sensor(s). Model: _ c� O Piping Sump / Trench Sensor(s). Model: O FBI Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Gd'Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: E3 Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model FMcw A 0 U1> ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify ui ment t and model in Section E on Page 2). 13 Other (specify ui ment t and model in Section E on Pae 2). Dispenser ID: L Dispenser ID: it Dispenser Containment ensor(s). Model: _ .fAb Y qPDispenser Containment Sensor(s). Model: O Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment FloatW and Chain(s). ❑ Dispenser Containment Float and Chain(s). Dispenser ID: Dispenser ID: 7 ispenser Containment Sensor(s). Model: 0 Dispenser Containmenttensor(s). Model: ❑ 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: ❑ 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 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 verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generatin reports, I have also attached a copy of the reportL(heck all that apply): ❑ System set-up ❑ A or, repot Technician Name (print): f - C o f==Gv2A "� Signature: Certification No.: TRIANGLE ENVIRONMENTAL, INCe;w License. No.: 09 Testing Company I2��}t�• . _ . Phone No.:( Site Address: 61 ° CA Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification