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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 Piot Plan showing the layout of monitoring equ�ipm� t. For any equip capable of gene uch reports, I have also attached a co of rt; (check all that apply): GW]ys set-up Alarm Technician Name (print): Signature: Certification No.:.4-b -&-� 14? Z License. No.: /I� ` Testing Company N me: Phone No.:(�DK ) � r Site Address: , Date of Testing/Servicing: J& �vJ Page 1 of 3 Monitoring System Certification D. Results of Testing/Servicing 03/01 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority 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 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 InformaiC Facility Name: Bldg. No.: Site Address: City: Zip: Facility Contact Person: W Contact Phone No.: ( �j`7 )4 7� )� Make/Model of Monitoring System: �� SCS _ Date of Testing/Servicing: (0 / / d B. Inventory of Equipment Tested/Certified Check thea ro riate bo es indicatespecific a ui ment inspected/serviced: Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: WAnnular Space or Vault Sensor. Model: r-P2r ZAR ❑ In -Tank Gauging Probe. Model: SPAnnular Space or Vault Sensor. Model: - 9,2 — ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify a ui ment a and model in Section E on Pae 2). ❑ Other(specify a ui ment a and model in Section E on Pa&e 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (sgecify equipment t e and model in Section E on Page 2). ❑ Other (s ci equipment a and model in Section E on Pa e 2 . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). El Shear Valve(s). ElDis enser Containment Floats and Chain(s . ❑ Dis enser Containment Floats) and Chains . Dispenser ID: Dispenser ID: Cl Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ElShear Valve(s). ❑ Dis enser Containment Float(s) and Chains . ❑ 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 Floa s and Chains . ❑ Dis enser Containment Floats 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' checklists) necessary to verify that this information is correct and a Piot Plan showing the layout of monitoring equ�ipm� t. For any equip capable of gene uch reports, I have also attached a co of rt; (check all that apply): GW]ys set-up Alarm Technician Name (print): Signature: Certification No.:.4-b -&-� 14? Z License. No.: /I� ` Testing Company N me: Phone No.:(�DK ) � r Site Address: , Date of Testing/Servicing: J& �vJ Page 1 of 3 Monitoring System Certification D. Results of Testing/Servicing 03/01