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B 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. GeneralInformati Facility Name: tom/ Bldg. No.: Site Address: ��,Sy� � ✓i SLr A City: �� Zip: Facility Contact Person: /y/cContact Phone No.: Make/Model of Monitoring System: % S' 3 3� Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified P10 57Z- 1-192 2' - d 01 Check the appropriate boxes to indicate specific equipment inspected/serviced: T,a�k ID' ~ Tank ID: 9 >' 71, -Tank Gauging Probe. Model: / /� / ❑ In -Tank Gauging Probe. Model: 0�Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 1 y ❑ Piping Sump / Trench Sensor(s). Model: u ❑ 'll Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 5RP- ❑ Mechanical Line Leak Detector. Model: 5 ' /Y < /� ❑ Electronic Line Leak Detector. Model: ❑ Pectronic Line Leak Detector. Model: Tank Overfill/ High:: r. Model:OP ov - eff i/,,"— ®'Tank Overfill / High-Ley4j_ ter. Model:0 ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID• Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ 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: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical 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: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment typp and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containme t Sensor(s). Model: ❑ Dispenser Containment ensor(s). Model: ar Valve(s). 4>S ear Valve(s). ❑'Dispenser Containment Float(s) and hain(s). ❑ Dispenser Containment Float(s) and Chaih(s). Dispenser ID: Dispenser ID: O'giSpenser Containment Senso (s). Model:❑Dispenser Containment nsor(s). Model: k7 Shear Valve(s). h/ear Valve(s). ►spenser Containment Float(s) and Chain(s) � U -E ispenser 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). ❑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. 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) n cessary to verify that this information is correct and a Plot Plan showing the layout of monitoring t. Fo any equtpm capable of generating such reports, I have also attached a copy of the report; (check all that ap �pme asy set-up Alarm history report Technician Name (print): _Tom Corcoran Signature: Certification No.: UO License. No.: U _-2- 1K2_ G Testing Company Name: Triangle Environmental, Inc. Phone No.:(818)840 7020 Date of Testing/Servicing:�6 Site Address: ,p t M Page 1 of 3 03/01