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MONITORING SYSTEM CERTIFICATION For'Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.%, 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. General Information Facility Name: u .'� Bldg.No.: Site Address: , rr�,_� }LYn City: ArK N1 Zip: Facility Contact Person: CA by ine Y` Contact Phone No.: ( E ) 1S `SS E Make/Mode]of Monitoring System: " �7L Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a2propri2te boxes to indicatespecific equipment ins ected/serviced: ck 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: 3 Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s)! Model: Mechanical Line Leak Detector. Model: P £ IX Mechanical Line Leak Detector. Model: 'VOIC ' ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(speduequipment type and model in Section E on Pape 2). ElOther(specify equipment=and model in Section E on Pae 2). Tank Tank ID: 1 .1n-Tank Gauging Probe. Model: 't1V1 • ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: W Annular Space or Vault Sensor. Model: alt Piping Sump/Trench Sensor(s). ModelSk CA ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model: LP �Lh ❑ 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 tv a and model in Section E on PaFe 2). ❑ Other(s city eouipment tv and model in Section E on Pae 2). Dispenser ID: t Dispenser ID: $I Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). O Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment F1oat(s)and Chain(s). Dispenser ID: Dispenser ID: CSL 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). ❑ 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 in spected/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): 'I System set-up Z Alarm history report Technician Name(print): tne\tt W�v+n h Signature: �IrtwA4 1W Certification No.: J License.No.: Testing Company Name: r 1 Ay-,aj r? �_'V)V(r C)' 'Y1� (7� Phone No.: SiteAddress: �a 75 A1'lbv V Yl Date of Testing/Servicing: !Z) OL) Page I of 3 03/07 Monitoring System Certification