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MONITORING SYSTEM CERTWICATION 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 retort 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: 1-211K � _� / OA2 7 Site Address: /® d , Facility Contact Person: Make/Model of Monitoring System: City: %%UC/�T�✓ Bldg. No.: Zip: Contact Phone No.: (__) Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified®8- Check the appropriate boxes to indicate specific equipment inspected serviced: Tank ID: 777 Ta ank Gauging Probe. Model: A;` ,4 C ❑ In -Tank Gauging Probe. Model: - L- ❑ Annular Space or Vault Sensor. Model: 4 , nular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: c a er Pipmg Sump /Trench Sensor(s). Model: f5z (J ❑ Fill Sump Sensor(s). Model: ❑ Bili'Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: S -7P M 1- i i _ f� Mechanical Line Leak Detector. Model: ❑ Electronic Lane Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / H' or. Model: �ti/ e . d �r� d ❑ Tank Overfill / H - . Model: 41A ❑ Other (s ui ment and model in Section E on PaLe 2). ❑ Other (specify ui ent and model in Section E on Pae 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 (s ui ment = and'model in Section E on Pa a 2). ❑ Other (specify ui ment t ngg model in Section E on Pa a 2)_ Viser ID: 411z-- ser Containment Sen r(s del: ' r ID: Containment Se sor(s). Model: alve(s). KZEis=penser ar Valve(s). FDilspen. Containment Float(s) and Chain(s). 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 Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ElDispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). •If the facility contains more tanks or dispensers, coov 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' c klists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equip itL For an uipment capable of generatin reports. I have also attached a copy of the reportheck all thatapply): ystem set -u ❑ A pry repot Technician Name (print): i - a �- GU �� "� Signature: Certification No.: TRIANGLE ENVIRONMENTAL, INCb�,7Si ense.No.: 0 Testing Company 2525 W. BURBANK BLW. Phone No.:-) Site Address: i Date of Testing/Servicing:./ ~ Page 1 of 3 03101 Monitoring System Certification