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MONIT NG 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 —'chis form must be used to document testing and s r tip ,� pment. A separate certification or report must be�repared r each monitoring system control panel by the ekio a 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.�, � (! 17 A. General Facility Name: Site Address: City: Bldg. No.: _ Zip: Facility Contact Person: Contact Phone No.: (530 Make/Model of Monitoring System: -{ f. TLU5 - -350 Date of Testing/Servicing: B Z/ l 1 /P B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspect Tank ID: Tank ID: 16 In -Tank Gauging Probe. Model: r41110 O In -Tank Gauging Probe. Model: V47110 - 1 9 10 Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: q R '304 Piping Sump / Trench Sensor(s). Model: y 9-7.0 g %Piping Sump / Trench Sensor(s). Model: A Jb8' Fill Sump Sensor(s). Model: 'L _119 Fill Sump Sensor(s). Model: `4 Mechanical Line Leak Detector. Model.. Mechanical Line Leak Detector. Model: (Zs=X O Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 07Tank Overfill / High -Level Sensor. Model: fj4,i 390 —1 ca. R 14 Tank Overfill / High -Level Sensor. Model: $'_"l3 O - ► ® 9 ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). VT nk ID: Tank ID: ZTank Gauging Probe. Model: $ 310 --1 p41 ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: V. 9,_ ❑ Annular Space or Vault Sensor. Model: Pipfiig Sump / Trench Sensor(s). Model: V 2-0 Tc ❑ Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: V ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model; Electronic Line Leak Detector. Model: ❑ Electronic. Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: NVy = (d1 ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other jseecM S40ent type and model in Section E on Page 2 . ❑ Other (speciikequi= =e and model in Section E on Page 2). Dispenser ID: ?i _ _ Di penser ID: Dispenser Con inment Sensor(s). Model:&' lDispenser Confainment Sensor(s). Model: 1K Shear Valve(s). gi[ Shear Valve(s). ❑ Dispenser Containment Floats and Chats . ❑ Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: t o Dispenser Containment Sensor(s). Model: V %P- a �9, Dispenser Con 'nment Sensor(s). Model: O 7Shear Valve(s). Shear Valve(s). ❑ Dis ensei Containment Floats and Chain(s). tj Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser IDi Dispenser Contauunent Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser 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 eq ipment capable of generating such reports, I have also attached a copy of the report; ( ck all thata System set-up r histor or Technician Name (print): . c o Signature: Certification No.: 00 % - U 2 — Cr W fv License. No.: IW3115` Testing Company Name: Q Z mz&u Pyk - _rvt, C . Phone No.: @�,_) - W d _Site Address: 6,3© kav h ha, w ��' Date of Testing/Servicing: Z / i 1 Page 1 of 3 `' 03/01 Monitoring System Certification