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R 1 MONITORING SYSTEM CERTIFICATION For-Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.%, 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. General Informati Facility Name: . w'tL17(0 Bldg.No.: Site Address: 1� \ Y Citv:} �L Zip: Facility Contact Person: qq Contact Phone No.: ) Mike/Model of Monitoring System: C ®L 'tom �–V rC Date of Testing/Servicing: / 2 B. Inventory of Equipment Tested/Certified Check the appropriote boxes to indicate specific.equJpmeni inspected/serviced: Tank ID: Tank ID: ($In-Tank Gauging Probe. Model: 1. —' ❑ In-Tank Gauging Probe. Model: %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: O Fill Sump Sensor(s)'. Model- IX Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: ❑ Electronic Line.Leak Detector. Model: It Tank Overfill/Nigh-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Pae 2). Tank ID: Tank IID: I.In-Tank Gau 'ng Probe. Model: 0 In-Tank Gauging Probe. Model: Annular Space'or Vault-. ensor. Model ❑ Annular Space or Vault Sensor. Model: Piping Sump!Trench S6 sor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model- O Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model- Mechanical Line Leak Detector. Model: L ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: I&Tank Overfill/High-Level Sensor. Model:i O Tank Overfill/High-Level Sensor. Model: ❑ Other(s 1 f eoui ment type and model in Section E on PaFe 2). O Other(sEncify eouipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: W Dispenser Containment Sensor(s). Model: 'Shear Valve(s). Shear Valve(s). Dis enser Containment Flost(s)and Chain(s). Dis user Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: 1�t Shear V alve(s). O Shear V alve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: VNI ❑ Dispenser Dispenser Containment Sensor(s). Model: Containment Sensor(s). Model: Shear V alve(s).' ❑ Shear V alve(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. Certifleation -l certify that the equipment identified in this document has inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklist)necessary to verify that this information is correct.and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports;I have also attached a copy of the r ori:(check ak that apply): , System set-up larm hist reporA Technician Name(print): Mhie � Signature: It Certification No.: License.No.: Testing Company Name:#'(`� ` V®� Phone Site Address: 1 %Z"b\ Date of Testing/Servicing: % Page I of 3 03/01 Monitoring System Certification