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f 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 13, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be Dreaared for each monitorine 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: Bldg.No.: Site Address: �- L,��,/SC City: l/f� 'i� Zip: Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: Ylll TLJ I-6 Date of Te sting/Seryicing: / /d( B. Inventory of Equipment Tested/Certified Check the appronriate boxes to indicatespecific enuipment insnected/serviced: Tank ID: /d' K f,5 7 Tank ID: /.- K -0 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: Y / 0`Annular Space or Vault Sensor. Model: V le 3 0 d- 2'Piping Sump/Trench Sensor(s). Model: 07 DO? Wiping Sump/Trench Sensor(s). Model: VtZ ;),-)r ). Model: D�-Dr(s). Model: 21M-cchanical Line Leak Detector. Model: Ve� Fx(V 2 vlechanical Line Leak Detector. Model: 4)F-10-4't ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment tv a and model in Section E on Paee 2). ❑ Other(specify equipment tv a and model in Section E on Pane 2). Tank ID: l.,; /C c/d' Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: CTAnnular Space or Vault Sensor. Model: lrt7 .3 D/ 0-'Annular Space or Vault Sensor. Model: 0"Piping Sump/Trench Sensor(s). Model: Vd ?0Y fd Piping Sump/Trench Sensor(}). Model: Model: ❑Fill Sump Sensor(s). Model: R`Mechanical Line Leak Detector. Model: eJ FXIV a-Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment tv a and model in Section E on Page 2). ❑ Other(specify et ui ment type and model in Section E on Paee 2). Dispenser 1D: - - D_iss enser ID: (3�spenser Containment Scnsor(s). Model: VZ �OfS C'S Dispenser Containment Sensor(s). Model: ` e 3c.1 C•3'Tlear Valve(s). hear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s), ❑ Dispenser Containment Floats)and Chain(s). 09Dis enser ID: S -�e Diss enser ID: - ,> ispenser Containment Sensor(s). Model: X/I 2 C if of Dispenser Containment Sensors i Model V/1 c ❑ $hear Valve(s). C'rShear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment FloutO and Chuin(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Scnsor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s) and Chuin(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 cot•rect and a Plot Plan showing the layout of monitoring equipment. For any equipmen4r- of generating such reports,I have also attached a copy of the report;(check all that apply): ❑System set-up ❑Alary report Technician Name(point): John SchelleY teach Signature: Certification No.: 34yy License.No.: Testing Company Name: Scott CO of California Phone No.:( sin ) R95-73-11 .x _185 Site Address: �S L • wryC 1-4?)`/Z-0 Date of Testing/Servicing: zi--/2/0 t_ Page I of 3 03/01 Monitoring System Certification