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L MONITORING SYSTEM CERT CATION 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 retwrt must be p pared 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: — G/�G dJ �` Bldg.No.: Site Address: d.2 W�'►%s�C City: Zip: Facility Contact Person: Contact Phone No.:4220 g ) .'" D Make/Model of Monitoring System: / Date of Testing/Servicing: j6__t.217 B. Inventory of Equipment Tested/Cert��6'0''00 Check the ageroeriate boxes to indicate sESSTc ui ment ins ected/serviced: DT ID: �7 T ID: Fank Gauging Probe. Model: Tank Gauging Probe. Model: vl ' ular Space or Vault Sensor. Model: `fid y Mnular Space or Vault Sensor. Model: Y Piping Sump/Trench Sensor(s). Model: .2 Id 8' Piping Sump/Trench Sensor(s). Model: bZ C9 CIRff Sump Sensor(s). Model: FE*le Sump Sensor(s). Model: ICJ Mechanical Line Leak Detector. Model: � '�" chanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ctronicLine Leak ector. Model: O'Tank Overfill/Hig - sor. Model: t Tank Overfill/ Model: ❑ Other(specify 2qui2ment type and model in Section E on Page 2). ❑ Other(s ify 2quipment type and model in Section E on Page 2). T '9Tank ID• - ank Gauging Probe. Model: AA A4 ❑ In-Tank Gauging Probe. Model: pular Space or Vault Sensor. Model: �/�y 9 ❑ Annular Space or Vault Sensor. Model: Qr Piping Sump/Trench Sensor(s). Model: oZy 8 ❑ Piping Sump/Trench Sensor(s). Model: ❑ 1 Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ats !�w t ❑ Mechanical Line Leak Detector. Model: ❑ ectronic Line Leak Detector. Model: ❑ Electronic Lane Leak Detector. Model: Iff Tank Overfill/UtVTeve_1 re 8r7Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equiprncnand model in Section Eon Pa e 2). ❑ Other(s if SquiLnLent!=and in in Section E on Page 2). Dispenser IDDispenser ID: ❑ Dispenser Contaimnt Sensor(s). Model: L3 Dispenser Containment Sensor( Model: E3 Shear Valve(s). !g ❑ Shear Valve(s). 0 Dis nser Containment Float(s d Chain(s). 0 Dispenser Containment Float(s Chain(s). Dispenser ID• Dispenser ID• ❑ Dispenser Containment Se sor(s). Model: ❑ Dispenser Containment Se sor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis2oser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ODispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats 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/semAced in accordance with the manufacturers' guidelines. Attached to this Certification is information (eg. manufacturers' checkl' necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipilent. For any equi t capable of generatin reports,I have also attached a copy of the report heck aU that apply): System set-up ory repoge— Technician Name(print): 7• C o fLGa��°"� Signature: CertificationNo.: TRIANGLE ENVIRONMENTAL INC?,117SIi ense.No.: Dot -%Z.2 G Testing Company 2525 5 - BURBANK BLVD._ Phone No.:(G 1� Site Address: li u t( s Date of Testing/Servicing: o7 71 ✓� Page 1 of 3 03/01 Monitoring System Certification