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IONITORING SYSTEM CERTIFICATION For'Use By All Jurisdictions Within the State of California Authority Ciud: Chapter 6.i, Health and Safer, Code; Chapter 16, Division 3, Title 23, California Code of Regulations This Corm must be used to document testing and servicing of monitoring equipment. A separate certification or repon 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 Inform tion t` Facility Name: 115i C Bldg. No.: Site Address: 175(7;� City: Zip: 951aocl i Facility Contact Person: Contact Phone No.: ( ) 1 rck Make/Model of Monitoring System: ` -f 004 Z 2- Date of Testing/Servicing: / B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific ui mens inspected/serviced: Tank ID: Tank ID: CA In -Tank Gauging Probe. Model: Th In -Tank Gauging Probe. Model: 1A Annular Space or Vault Sensor. Model Annular Space or Vault Sensor. Model: M Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: O Fill Sump Scnsor(s). Mechanical Line Leak Detector. Model: — Model: •—• i t ❑ Fill Sump Sensor(s)'. 0( Mechanical Line Leak Detector. Model: Model: ro ❑ Electronic Line Leak Detector. Tank Overfill / High -Level Sensor. Model: _ Model: ❑ Electronic Line.Leak Detector. lk Tank Overfill / High -Level Sensor. Model: _ Modell. O Other (s ify equi ment type and model in Section E on Pa2e 2). O Other (specify equipment type 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.ensor. Model: _ ❑ Annular Space or Vault Sensor. Model: Piping Sump /Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: "�'40)dk%4 O Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: vonic Line Leak Detector. Model: n9W ❑ Electronic Line Leak Detector. O Tank Overfill / High -Level Sensor. Model: Model: Tank Overfill / High -Level Sensor. Model: ❑ Other (specify eoui went type and model in Section E on Pa e 2). ❑ Other (specify equipment type and model in Section E on Pae 2). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: '!1 Shear Valve(s). O Shear Valve(s). ❑ Dispenser Containment Floai(s) and Chain(s). O 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). Dis enser Containment Rost(s) and Chain(s). ❑ Dispenser Containment Flost(s) and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ODispenser Containment Floats) and Chain(s). 0 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 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 monitoringa uipment. For any equipment capable of generating such reports; I have also at attached a copy of the r ort: (check all thapply): System set-up Alarm history reporl Technician Name (print): n4 VAO –� ®� Signature: Cenification No.: nO CI 1 License. No.: Testing Companaf Name: t Phone No.: Site Address: Date of Testing/Servicing: Page I of 3 .ib. Monitoring Svstem Certification 03/01