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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 his form must be used to document-testing.and servicing of monitoring equipment. If more than one- ,onitoring system control panel is installed at the facility, a separate certification or report must be prepared for tch monitoring system-control panel by the technician who performs the work. A copy of this form must be ovided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local ;envy regulating UST systems within 30 days of test date. Instructions are printed on the back of this page. . General Information �7 iciliity Name: R(.-1/ J/L),z d (� Bldg.No.: to Address: } 7i City: Zip: edility Contact Person: Contact Phone No.: ake/Model of Monitoring System: Date of Testing/Servicing. . Inventory of Equipment Tested/Certified heck the appropriate boxes to indicate specific'equipment inspected/serviced: dile ID: Tank ID: Tank Gauging Probe. Model: 4 0 J Tank.Gauging Probe.: Model: ' �mnular Space or Vault Sensor. Model: W g,I _ Annular Space or Vault Sensor. Model: u/ .•�.' 3 �.. '-Piping Sump/Trench Sensor(s). Modck. VA 2 Q14iping Sump/Trench Sensor(s). Model: {1,c2- og gill Sump Sexisor(s). Model: ❑ Fill-Sump Sensor(sj.• Model: L0-.,2 a a Mechanical Line Leak Detector. Model: 2_6 L Q7 Moehanicai Line Leak Detector ' Model: ' U' JFiectronic Line Leak Detector. Model: ❑ nic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 014fank overfill I High-Level Sensor. Model: ,pispenser Containment Sersor(s). _Model: ❑ pisl3enser Containment Sensor(s). Model: Shear Valve(s). Shear Valvc(s)'. Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment t Floats)and Chain(s). Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipinent type and model in Sectiori.E on Page 2). '. ntilC 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 Seng. Model: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containmeent-Sensor(s). Model: Shear Valve(s). ❑Shear Valve(s). Dispenser Containment Float(s)and Cham(s). ❑ D' Containment Floats)and Chain(s). . Other(specify equipment type and model in Section E on Page 2). ® Other(specify equipment type and model in Section E on Page.2). Certification - I.certify that the equipment identified in this document was inspe cted/secviced.in accordance with the manufacturers' guidelines. Attached to-this•Certification is information (eg. manufacturers' checklists) necessary to verify that this information is correct and a Site Plan showing the layout of monitoring equipment. .For any equipment capable of generating such reports,I have also attached a copy of the(check all drat apply), •❑.System set-up report; 0 Alarm history report !chnician Name(print): Cert./L;ic.No.: Signature: ' Phone'No.: ,sting Company Name: �) . '