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a 0 -ICIR ION O SYST CERT 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 Chis form must be used to document- testing . and servicing of monitoring equipment. If more than one nonitoring system control panel is installed at the facility, a separate certification or report must be prepared for :ach 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 tgeney regulating UST systems within 30 days of test date. Instructions are printed on the back of this page. &. General Information / .i< Bldg. No.: . act tty iite Address: ( �� `J (�1 City: Zip: riacilityContact Person: Contact Phone No.: viake/Model of Monitoring System: �/ � Date of Testmg/Servicing: 3. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins rank ID: _0 t Tank Gauging Probe. Model: ular Space or Vault Sensor. Model: _ rg sump/Trench Sensor(s). Model: :1 Fill Sump Sensor(s)- Model: ❑ Mechanical Line Leak Detector. Model: :1 Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Dispenser Containment Sensor(s). . Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID ❑ Ian -Tank Gauging Probe. Model: lT Annular Space or Vault Sensor. Model: Q�ping Sump / Trench Sensor(s). Model: ' ❑ Fill Sump Sensor(s)._ Model: . ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model. ❑ Tank Overfill / High -Level Sensor. Model: Cl Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: �1 i ❑ In -Tank Gauging Probe.: Model. Qkel(unular Spam or Vault Sensor. Modcl: ting Sump / Trench Sensor(s). Model: ❑ Fill -Sump Sensor(s). • Model: ❑ Mechanical Line Leak Detector. Model: ' ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Dispenser Containment Scusor(s). Model: ❑ Shear Valve(s): ❑ Dispenser Containment Floats) and Chain(s). ❑ Other (specify equipment type and model in Scctiori.E on Page 2). Tank ID: ❑ In Tank Gauging Probe-'. Model: ❑ Annular Space or Vault Sensor. .Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s).. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Dispenser Containment Sensor(s). Model: ❑ .Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Cl Other (specify equipment type and model in Section Eon Page 2). 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 Site Plan showing the layout of monitoring equipmVAlar7 or any equipment capable of generating such reports, I have also attached a copy of the (dieck all that apply):em set-up report; history report+ i Technician Name (print): �F/ifl Cert./Lic. No.: Signature: Testing Company Name: T �' Phone'No.: l ' 00— r1KQ1 0 <[/t CMn