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MONOJRING SVSTEM CERTIROTION or Use Bn .1 // Jru isc/ictiorrs (1 'illrirr IGe ,Slide of C (11 fi)l•niu Awhorihv C'ilecl: Chctplel- 6.7, I-Ieullh anal sglLly Code; Chupler 16, Division 3, Tille 23, 011ifbr•rria Code of Rc,,,,u1a1iorj,s- 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. General Information. Facility Name: Site Address: A/I/�s/) &,A Facility Contact Person: Make/Model of Monitoring System: P. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauinment inspected/serviced: Bldg. No.: City: S'�� Zip: �� t _ Contact Phone No.:( ?)�� Date of Testing/Servicing: !/Zw) / 44 Tank ID: Tank ID: a-< 2 In -Tank Gauging Probe. Model: Al Annular Space or Vault Sensor. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: - �Piping Sump / Trench Sensor(s). Model: ,� . Piping Sump /Trench Sensors}. Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Line Leal: Detector. Model: uaas&taLine Leak Detector. Model: Electronic Line Leak Detector. Model: 9- _ Electronic Line Leak Detector. Model:— ❑ Tank Overfill / High -Level Sensor. Model: rq ❑ Tank Overfill / High -Level Sensor. Model: - LJ Other (specify equipment ty e and model in Section E on Page 2). ❑ Other (specify equipment ty e and model in Section E on Pa e 2). Tank ID: Tank ID: 4 In -Tank Gauging Probe. Model•G r ❑ In -Tank Gauging Probe. Model: 04 Annular Space or Vault Sensor. Model: ❑ 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: Q " Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. . Model: P ❑ Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci a ui ment type and model in Section E on Pa a 2). ❑ Other (s eci a ui ment type and model * Section E on Page 2). Dispenser ID: -T-2 penser ID; Dispenser Containment Sensor(s). Model: - - Dispenser Containment Sensor(s). Model: AQ Shear Valve(s). AShear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: A- L4 Dispenser ID: Dispenser Containment ensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: "1 Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). ID: Dispenser ID: kDispenser Dispenser Containment Sensor(s). Model: - El Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). is enser Containment Float(s) and Chain(s). Q. Dispenser Containment Float(s) and Chain(s). ..' . y «aim VI U16pulwciN, cuNy uus wi,u. mcurae tnrormation for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/seryiced 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 equi ment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all !/nal apply): ]Alarm history report Technician Name (print): �iw� n��,� Signature:0 C'� �t 2 �; 3 2 r% ~ U 7 - Certification No.: f/ License. No.: Testing Company Name:.;,,. = .. ,,, .. a� ... - _ _...wr Phone No.:(_I-� Q /jam Site Address:' Date of Testing/Servicing: jZ110 j6. Page I of 3 Monitoring System Certification A Results of Testing/Servicing M 03/01