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A Page 1 of 3 03/01 Monitoring System Certification J r 'QUALITY TESTING OF UNDERGROUND TANKSATAFFORDABLERATES' Post Oce Box 36 Thornton, Car: 95686 (209) 794-0102 FAX 794-0112 General Information Facility Name: --��ps0h�',� Bldg. No.: Site Address: City: Zip: --4-57:2 725 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: ! Date of Testing/Servicing: / y B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a ui meat inspected/serviced: Tank ID: t a a j Tank ID: ❑ In -Tank Gauging Probe. Model: 9 ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: L 0 a ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: /- 3 3 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 4_5 ❑ 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 (s eci ui ment a and model in Section E on Page 2). ❑ Other (s eci equipment a 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: L3 Annular Space or Vault Sensor. Model: ❑ Piping Sunip / Trench Sensor(s). Model: 13Piping 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 (s eci ui ment =and model in Section E on Page 2). ❑ Other (s eci a ui ment a and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Sensor(s). Model: ❑ Dis enser Containment Floats) and Chain(s). ❑ Shear Valve(s). ❑ Dis eraser 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). (3 Dispenser Containment Floats) and Chain(s). *If the facility contains more tanks or dispensers, copy this form Include inforination 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) 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 report; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): F G'i9m Sgnatui:,: Certification No.: License. No.: Page 1 of 3 03/01 Monitoring System Certification