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_ 09/19/2001 11:15 2094683433 FIFTH FLOOR PAGE 02 - MONITORING SYSTEM CERT ICAO N For Use By.411 Jurisdictions Within the State jsaTatc rnt Authority Cited. Chapter 6.7, tlealth and Safety Code; Chapter 16, Division 3, California Code of Regtrintions This form must be used to docusz>eat testing and smvicine of monitoring equipment. t' nor or re must be aced for each monitoritt� sy irtn control pane} by the technician who performs the work. A copy o this form must be provided w the tack system owner/operator. The owner/operator must subruit a copy of this form to the local ag ocy regulating UST systems within 30 days of test date. I A. General information Facility Nana: Site Address: 3i!"' `' `cl�r%i City �: ver Zip: 9 - Contact Pbon No.-. Faeitaty Contact person: Date f Testing/Servicing: � !_ / C / Makc/Model of Monitoring System B. Inventory of Equiiproent Tested/Certifed Check the appropristr bozos to indicstc specific egaipment inspeeted/3krvicrd' ulna uc, ..-,.........,.._.....__-�- • --- - - ut .If the facility contains more tanks or dispensers, copy this form_ Include informatiou. for every.'ta C. CerttfiCahOn - I certifp that the equipment identified in this document seas inspected/: guidelines. Attached to this Certiftcatiow is information (e.g. tmnufactarers' checklist correct and a Plot Plan Sho,aiug the layo tt of monitoring equipment. System Fr y equipment Alam attached x copy of the report; (check all that apP17): Ss tr-up Technician Name (print): Certification No.: Testing Company Name: Site Address: Monitoring Systern Certification i License. No.: Pas 1 of 3 Moder: Isor. Model: Dr(s). Model: Model. ctor. Model: tor. Model: Sensor. Model: me and model in Section E on Pa_e 2). _ Model: Sensor. Model: iensot(s). Model: Model: Detector. Model: elector. Model: :vel Sensor. Model: Mt. type and model in Section E onPaec 2). t Scnsor(s)_ Modcl: �W t Flont(s) and Chain s) — I Sensor(s). Model: t Floats) and Chain(s). t Stnsor(s). Model*, a float(s) and Chain(s). - — ard dispenser at the facility. ,viced in accordance with the manufacturers' necessary to verify that this Information is apable of generating snob reports, I have also history report - No.:( ate of Testing/Servicing: —j—l- 03101 Tank ID: Tank ID: ❑ in -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe ❑ Annular Space or Vault O Annular Space or Vault Sensor. Model: h S ❑Piping Sump p / Trench enc ❑ Piping Sump / Trench Sensor(s). Model: renc ❑ Fill Sump CI Fill Sump Scnsor(s). Model: O Mechanical Line Leak 1 O Mechanical C ire Leak Detector. Model: ❑ Electronic Linc Leak D Q Electronic Line Leak Detector. Model: — ❑ Tank Overfill/ Nigh -Le ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other Mecify equipment type and model in Section E on Page 2). 0 Other s eci u' me Tank ID: Tank ID: El its -Tank Gattgino Probe. Modcl: 0 1n -Tank Gauging Probt Q Annular Space or Vsttl' ❑ Annubf Space or Vault Sensor. Model: Trench! pining Sump / Tren p I Piping Sump i Trench Sensor(s). C3 Piping Modcl: Q Pip Sump r Cl Fill Sump Sensor(s). Model: Model: ❑ Mechanical Line Leak ❑ Mechanical Line Leak Detector_ 0 Electronic line Leak ❑ Electronic Linc Leak Detector. / High -Level Sensor. Model: Model: ❑ Tank Overfill / High- ❑ Tank Overfill ❑ Other ( eeif equipment and model in Section E on Pae 2). 1] Other i e ui % 1 � j v 1 c/1 1)ispcnser ID: SII Dispenser Imo D Dispenser Containment Sensor(s). Model: '' / ❑ Dispenser Contamrne 0 Shear Valve(s). 53 Shear Valve(s). Dispenser Containment laoat(s) and Chain(s). Dispenser Containm Ilispemser ID: Dispenser ID: D ❑ Dispenser Containment Scnsor(s). Modcl: ❑ Dispenses Conminmc E) Shear Valvt(s). D Shear Valve{s). Cl Dispenser Containment Floats and Chain(s). ❑ Di r Containmc Dispenser ID: Dispenser ID: ❑ Dispcnsa Containment Sensor(s)_ Model: ❑ Dispenser Containme Q Shear valve(s)- D Shear Valve(s)- n nic�cvt Contninm ulna uc, ..-,.........,.._.....__-�- • --- - - ut .If the facility contains more tanks or dispensers, copy this form_ Include informatiou. for every.'ta C. CerttfiCahOn - I certifp that the equipment identified in this document seas inspected/: guidelines. Attached to this Certiftcatiow is information (e.g. tmnufactarers' checklist correct and a Plot Plan Sho,aiug the layo tt of monitoring equipment. System Fr y equipment Alam attached x copy of the report; (check all that apP17): Ss tr-up Technician Name (print): Certification No.: Testing Company Name: Site Address: Monitoring Systern Certification i License. No.: Pas 1 of 3 Moder: Isor. Model: Dr(s). Model: Model. ctor. Model: tor. Model: Sensor. Model: me and model in Section E on Pa_e 2). _ Model: Sensor. Model: iensot(s). Model: Model: Detector. Model: elector. Model: :vel Sensor. Model: Mt. type and model in Section E onPaec 2). t Scnsor(s)_ Modcl: �W t Flont(s) and Chain s) — I Sensor(s). Model: t Floats) and Chain(s). t Stnsor(s). Model*, a float(s) and Chain(s). - — ard dispenser at the facility. ,viced in accordance with the manufacturers' necessary to verify that this Information is apable of generating snob reports, I have also history report - No.:( ate of Testing/Servicing: —j—l- 03101