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• t Appendix'VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httf2:1/www.waterboards.ca•�ay.) MONITORING SYSTEM CERTIFICATION For Use By A#Jurisdictions Within the State of California Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, T°itie 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: _ !" Bldg No,: SiteAddress: ,�;�, t�f"I t,l city: �'?`��%�� °..:�- zip= Facility Contact Person: Contact Phone No.: ) _ Y Make/Model of Monitoring System: _ Date of Testing/Servicing:" (•.__`) B, inventory of Equipment Tested/Certified Check the approeLlats boxes to indicate specific a ui ment Instj Pectecilserviced, Ta ID:�,, sl Tania ID: [Tank auging P obe. Model: _ o In-Tank Gauging Probe. Model:. nnular Space or Vault Sensor, Model u Annular Space or Vault Sensor. Model: r✓Piping Sump/Trench Sensor(s). Model: C Piping Sump I Trench Sensor(s). Model. +II Sump Sensor(s). Model: ,wm u Fill Sump Sensor(s). Model: M'echanicat line Leak Detector. Modal: t I Mechanical Line Leak Detector. Model: rectronic tine Leak Detector: Model: j Electronic Line Leak Detector. Model: ank Overfill/High-Level Sensor, Model: u Tank Overfill I High-Level Sensor. Model: Other(specify a ui mens t e and model in Secr,on E on a ;;i Other(specify enuipmeni type and model in Section E on Pa 2). To C ID: f Tank ID-, ��33++��,Tank GaugingPlobe, Model, In-Tank Gauging Probe. Model', Z' Annular Space or Vault Sensor, Model:_ Annular Space or Vault Sensor. Model. Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s), Model; r. Rll Sump Sensors}, ModeL• i: Fill Sump Sensoria), Model:y+'Mechanical Line Leak Detector, Model t:- Mechanical line LeakDetector: Model`. ;.:>_,Rfectronic Line Leak Detector. Model: _ t1 Electronic Line Leak Detector. Model: Pt'Tank Overfill/High-Level Sensor, Model: ?� Tank Overfill I High-Level Sensor. Model: .o Other�amcifx e u meat a and model in Section E on P C Other(SDOdtV Wit Ment type and model in Section E on Pa 2). D>p enser ID, Dispenser 10: fxpanser Conte Ment Sensors), Madel; C Dispenser Containment Sensor(s). Model: Z'Shear valve(s), i' Sheer Valve(s). Dis enser Conta' nt FbalW and Chain(s). LN Dispenser Containment Floats and Chainis). �spenseriD: V, ,.� Dispenser ID: (dispenser Co ntaVneht S®nsor(s)• Model:_ T r Dispenser Containment Sensor{s}, Model: ;' Shear Volve(s). ,n Shear Valve(s), Dix enser Containment Floats and Chaia s, f i Dis enser Containment.Floats and Chains. Dispenser ID: Dispenser ID: Dispenser Con lainment Sonsor(s). Model: C Dispenser Containment Sensor(s). Model: , 4� Sherr Vatve(s), o shear Valve(s). LQ_Dis user Contairfrnent Floats and Chains 0 Dispenser Containment Floal 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 we`s)inspectedtserviced In accordance with the manufacturers' guidelines. Attached to this certification is information(e,g.manufacturers"c ecklists)necessary to verity that this information Is correct and a Plot Plan showing the layout of monitoring equipment. For any aquiITa t capable generating such reports,I have also attached a copy of the report;(check all that apply): KSystem set-up XAtarm ttist ryreport Technician Name(print): lixvmik Signature f` Certification No.: Licence.No.: / Testing Company Name; rf L) 1(– — _ Phone No.:(_� r Testing Company Address: t � .47 I 16di to _ Date of TesiingfServicing Monitoring System Certification Page t of 4 12/07 1 121/07