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Ul.1-1 J-4uU1 1•et3 ULN I FKHL F'L I KULEUM MA I NT 9254628352 P.02 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Aziehority 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 cern tcation or,report mot be preriared for each onitoz_na syste contr to 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: —�WGt= �� ^— .Citi- LAG— B1dg.No.:SP-] `k Site Address:5 0 12 " ' , 40 fl-- Cita: Zip' R53:2(.= — Facility Contact Person: �' iQv SQL Contact Phone No.: Make/Model of Monitoring System:COt G Date of Testing/Servieing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates esit-ic a ui ment ins eetedlservieed; Tank ID: L• u`..;� � Tank ID: tZ4 L 16 In-Tank Gauging Probe. Model:• a !37.0 4 6 bill to-Tank Gauging Probe. Model. ><31b2 ink '® Annular Space or Vault Sensor. Model: 10 Annular Space or Vault Sensor. Model: 7•- $Piping Sump/Trench Sansor(s). Model: it Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: Q Mechanical Line beak Detector_ Model: 0 Electronic Line Leak Detector. Model: _ ❑ Electronic Line Leak Detector. Modal: 0 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor, Model: 0 Other(seecia equipment a and model in Section E on Pa a 2). 0 Other(51)CCitL a ui meta Sao and model in Section E on FaLc 2). TanklD: Tank M-. _ 0 In-Tank Gauging Probe. Model: ❑ In-Tattk Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model; ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model. 0 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: _ ❑ Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector, Model: 0 Electronic Linc Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: Q Tank Overfill/High-Lcvet Sensor. Model Cl Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(s eci c ui ment a and model in Section E on Pae 2). Dispenser FD, ( Dispenser ID: * Dispenser Co tainment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: Q Shear Valvc(s). Q Shear Valve(s). Dis enser Containment Floats and Chains. Dis cnser Containment Floats .and Chain s Is ispenser rD: Dispenser tU: ❑ Dispenser wAainment Sensor(s). Model: Cl Dispenser Containment Sensor(s). Model: _ ❑ Shear Valve(s). Cl Shear Valve(s). Dis enser Containment Floats and Chaire s . Q Dis onset Containment Ftoa s and Chains, ispenser ID: Dispenser M: 0 Dispenser Containment Smsor(s). Model: ❑ Dispenser Containment Sensor(s). Model: • Shear Valvc(s). ❑ Shear Valve(s)- ❑Dis cnser Containment Float(s)and Chain(s). Q Dis enser Containment Fioat s and Chains, *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' cheekiists) 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; (clreck all I at ap,,pt %System set-up 9 Alarm history r ort Technician Name(print): r.t'� ( Signature _ Certification No,: License.No.: 'resting Company Norrie: t'+,rD;rt,(A Sp4'm r G 0 w, Phone No.! 2.5 )��aL� Site Address: Date of Testing/Servicing: UN-036-1/4 Page 1 of 3 Rev.06104/01 amw.anldocs.org