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MONITORING SYSTEM CERTIFICATION For'Use By All Jurisdictions Within the State of California Awhority Cited: Chapter o.7, Health and Safer),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 Informatioll Facility Name: Q t cw`� Bldg.No.: Site Address: �� F,• F��V�OIr1 &yf City: 1"1 Zip: 9�S3P�,S Facility Contact Person: ©wy%er Contact Phone No.: 464—(COT Mike/Model of Monitoring System: colyborcc _ FYY%L Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the&ppropristt boxes to indicate specific.equipmevi inspected/serviced: Tank ID: Tank ID: dG In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: 11 Annular Space or Vault Sensor_ Model: ❑ Annular Space or Vault Sensor. Model: M Piping Sump/Trench Sensor(s). Model: O Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s)`. Model: MkM Mechanical Line Leak Detector. Mode]: ��o bei El Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Electronic Line.Leak Detector. Model: I�Tank Overfill/High-Level Sensor. Mode]: Chp M/ O Tank Overfill/High-Level Sensor. Model: O Other(specify equipment type and model in Section E on Page 2). O Other(specify equipment type and model in Section E on Pae 2). Tank ID- Tank ID: Ok In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault.knsor. Mode]: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Mode]: O Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: (�t Mechanical Line Leak Detector. Model: V—. Q CL_ O Mechanical Line Leak Detector. Mode]: ❑ Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: V Tank Overfill/Nigh-Level Sensor. Model: nV►v✓ O Tank Overfill/High-Leve]Sensor. Model: ❑ Other(s ifv ecui ment type and model in Section Eon Pa e 2). O Other(sREcify equipment type and model in Section E on Page 2). Dispenser TD: IfCk. Dispenser TD: 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 Float(s)and Chain(s). Dispenser TD: Dispenser TD: Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: Shear Valve(s). O Shear Valve(s). O Dispenser Containment Float(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser TD: Dispenser TD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s).' ❑ Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s): •]f 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/ser•viced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e-g. manufacturers' checklist) 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;l have also attached a copy of the re ori:(check all that apply): �i System set-up farm hist ry rep rt / Technician Name(print): Rrinn'e trtiC� Signature: �ar Certification No.: License.No.: 0,39 7 1 Testing Company Name: �Y Ay1� f!VtV%ro�#lpJAL Phone Noj '%%2 ) `DC.- r76 6* Site Address: ea ��o� V� Date of T estjng/Servicing: % �I Page I of 3 03/01 MonitorinE Svstem Certification