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E <br />Appendix VI MAY 0 4 2011 <br />(Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hAp-,'!-w—ww_-watPrboard&,Ca- �iv,) <br />gg_ <br />MONITORING SYSTEM CERTIFICATION <br />For Use By Aff Jurisdictions Within the State of California PMW AIM <br />Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Calffomia Code of <br />Regulations <br />This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for <br />each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system <br />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. <br />A. General Information <br />Facility Name:7 -Z C -4p/3 <br />- Bldg. No.: <br />Site Address: CRY: ILAilL-lez Zip: <br />fP cc, <br />Facility Contact Person: Contact Phone No.: <br />MakeAAodel of Monitoring System-712—� Date of Testing/Servicing: <br />B. Inventory of Equipment Tested/Certified <br />C. Certification - I certify that the equipment Identified In this document was Inspected/serviload in accordance with the manufacturers, <br />guldeffnes. Attached to this Certification Is Information (e.g. manufacturers' checklists) necessary to verify that this Information Is correct <br />and a Plot Plan showing the 18YOut of monitorft equipment. For any equIprn=ca=e of generating such reports, I have also attached a <br />copy of the report; (chex* all thatlapply): - System set-up - Alarm hi re <br />Technician Name (print - J it <br />Signature: <br />Certification No.: <br />Testing Company Name: <br />Testing Company Address: <br />Monitoring System Certification Page I of 4 <br />Date of Testing/Servicing: <br />12107 <br />2J21/07 <br />