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MON16RING SYSTEM CERTIFATION For Use 6), .-111 Jill lse lit Wons 17'iihin the Slide of California Awhoril)% Cited: C'hapler 6.7, tlecrllh and Safeh1 C'Ocle; Chapter 16, Division 3, Tille 23, California Code of Re;arlalion,r 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 1l1UstW51lnit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: f 00 1) r Bldg. No.: Site Address: a -vb Ci C h': �✓ftx�� Zip: Facility Contact Person: p p,( Contact Phone No,:( 1-01 Make/Model of Monitoring System: 06L Date of Testing/Servicing: / 0 / B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snecific eauinment inspected/serviced: Tank ID: &7f �� L_ Tank ID: •. In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: OPT(CZ)4- 50N5 ❑ Annular Space or Vault Sensor. _ Model: Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: AMechanical 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: ❑ Tank Overfill / High -Level Sensor. Model: (s ecify e ui ment type and model in Section E on Page 2). ❑ Other (specify e ui nnent type and model in Sectioi on Pa e 2). Tank ID: �� Tank ID: n -Tank Gauging Probe. rL3Other Model: 47 A67 ❑ In -Tank Gauging Probe. Model: nnular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: iping Sump / Trench Sensor(s). Model: t ❑ Piping Sump / Trench Sensor(s). Model: ill Sump Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: IV ❑ 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. Mod : ❑ Other (seecify a ui Ment ty a and model in Section E on Page 2). ❑ Other (specify a ui ment a and model in Section E on Page 2). Dispenser ID: f �� Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: A Shear Valve(s). ❑ Shear Valve(s). Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: UF Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ 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). A ❑ 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 equ' ment. For any equipment capable of generating such reports, I have also attached a copy of' the report; (check a// that app/y): S i`�ti�Alarm history report Technician Name (print): rlle ;,23—,0 Signature: Certification No.: License. No.: W 5-24 33a — or Testing Company Name: _ Phone No.: Site Address: > p i.�rD� Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification D. Results of Testing/Servicing ' RAV I b l �.,'� `A,' I