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MON&RING ,SYSTEM CERTIFISATION 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 sepgLak certification or rert must be prepared for each monitoring Ustem control panel by the technician who performs the work. A copy of this form must be provided to the ta The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test dakFECEI D A. General Information 1 VT 12 2011 Facility Name: Bldg. No.: Site Address: r Z 34,.I � . City: Sicr- k'� E O�Eui=aLTH Facility Contact Person: ,.9y1 L— Contact Phone No.: (Z &C, ) 4VhU-/4E" Make/Model of Monitoring System: r/C.tc i 1 go r Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Cheek the nnnrnnAftt. Mva to indiente Rneeife equipment insnected/serviced: 0 <-- .�- Tank ID:ing FTankID:�� Probe. Model: ❑ In -Tank Gauging Probe. Model: e or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Trench Sensor(s). Model: .7 C)SC [�}'�iping 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 equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: ®Ic 7 - Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: I;Jfiping Sump / Trench Sensor(s). Model: ZOY ❑ 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 equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: l 1 Z Dispenser ID: 3 1-1 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ispenser Containment Float(s) and Chain(s).ispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID:( 0 Dispenser Containment Sensor(s). Model ispenser Containment Sensor(s). Model: -ZC% ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(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 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 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; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Cj %je Signature: Certification No.: /3 z/0 L C, License. No.: ? 40 Ap !`'3 r Testing Company Name: /`✓� l,, %� Phone No.: (4lb ) en S-- 1 S 3 ., Testing Company Address: iP 0 C o� ��Sds-,r 4P Q5W;3L7 Date of Testing/Servicing: O / Page 1 of 4 UN -036 -1/4 www.unidocs org Rev. 01/17/08