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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. A. GeneralInformatio> Facility Name: Ile Bldg.No.: Site Address: I�e2 ��'1/.< t�? /+ice City: '7/ b Dom/ Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System- � � Date of Testing/Servicing: B. Inventory of Equipment Tested/&ert f V45 60-'00/ Check the aggroLnate boxes to indicate sESEffic Equipment ins ected/serviced: Tm&ID: ? T ID: ank Gauging Probe. Model: A� Tank Gauging Probe. Model: M A 5^ pular Space or Vault Sensor. Model: M OAnular Space or Vault Sensor. Model: 5"07- 0 ' — Piping Sump/Trench Sensor(s). Model: S' lY Piping Sump/Trench Sensor(s). Model: 6z ❑hili Sump Sensor(s). Model: -TOLl 15M Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: t G t W " echanical Line Leak Detector. Model:_1!W;/0- Cl F nv❑ Electronic Line Leak Detector. Model: U Ell ctronic Line Leak tor. Model: eTank Overfill/High-ebmt 5ffsor. Model: ❑"Tank Overfill/ Model: ❑ Other(specify equiLiEnt type and model in Section E on Page 2. ❑ Other(s i ui ment type and model in Section E on PaLe 2). T Tank ID: - ank Gauging Probe. Model: AA Af ❑ In-Tank Gauging Probe. Model: Anular Space or Vault Sensor. Model: �)U 9 [3Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ow£' 13 Piping Sump/Trench Sensor(s). Model: ❑ Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: F&Pgl iP4 E3 Mechanical Line Leak Detector. Model: ❑ ectronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model:Iff Tank Overfill/Ut�vel a odel: L3 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui men and model in Section E on Page 2. ❑ Other 0 if ui ment t and m in Section E on Pae 2). Dispenser ID:_ Dispenser ID: 13 Dispenser Contain nt Sensor(s). Model: E3 Dispenser Containment Sensor( Model- 0 Shear Valve(s). 13 Shear Valve(s). 13 Dispenser Containment Floats d Chain(s. ❑ Dis ser Containment Floats Chains . Dispenser ID: a1' Dispenser ID: 13 Dispenser Containment S sor(s). Model: LI Dispenser Containment S sor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). O Dispenser Containment Floats and Chain(s). Dispenser ED: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: E3Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). 13Shear Valve(s). [313ispenser 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/se ced in accordance with the manufacturers' guidelines. Attached to this Certification is information(e.g. ufacturers' checkl' necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring eqm ent. For any aqui nt capable of generatin reports,I have also attached a copy of the report; all that apply): System set-up ory repo Technician Name(print): !- C o/0—Gd ILA Signature: CertificationNo.: TRIANGLE ENVIRONMENTAL, INCb`17'6 ense.No.: 002 -%za G �2525[ BURBANK Glfi 8/6- 6Z,6 Testing Company li _ Phone No.:� Site Address: ° Date of Testing/Servicing: il, 710, Page 1 of 3 03101 Monitoring System Certification I