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MOP&FORING SYSTEM CERT4ATITOPIT /-or Use 8),AH urisclicNons LI"ilhirr the .SI(jIc nJ'C'ali/rui�iu Aulhoril);C'iled: C'hapler•G.7, Hcallh and Sufely Cocle; Chtjpier 16, Dn,ision 3, Tile 23, C'ul!%nrniu Co�le of Rc;gululions This form must be Used to document testing and servicing of monitoring equipment. A separate certification or report most be prepared for each monitorinry system control Danel 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 fthe local agency regulating UST systenis within 30 days of test date. A. General Information ry Facility Name: /V 9 /T/ Bldg.No.: Site Addles: 3 G Y City: Zip: 957-07 Facility Contact Person: Contact Phone No.: ( ) IV7 yL Make/Model of Monitoring System: &"Ce 16cr 7(,5"350 Date of Testing Servicing: B. Inventory of Equipment Tested/Certified Checlt the a ro riate boxes to indicates ecific a ui ment inspected/serviced: Tank TanIt ID: �5 In-Tank Gauging Probe. Model: MA 1 _ 111 In-Tank Gauging Probe. Model: VIA&,Annular Space or Vault Sensor. Model:_ O iq Annular Space or Vault Sensor. Model:_ yg �-Piping Sump/Trench Sensor(s). Model: 357- Jq Piping Sump/Trench Sensor(s). Model: J& Fill Sump Sensor(s). Model: it Fill Sump Sensor(s). Model: - 7-p— ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model:_ gi-Electronic Line Leak Detector. Model: PLo-D At Electronic Line Leak Detector. Model: L(.� ❑ 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 t ie and model in Section E on Page 2). Tank ID: Tank ID: Z„ ❑ In-Tank Gauging Probe. Model: Q In-Tank Gauging Probe. Model: (� ❑ Annular Space or Vault Sensor. Model: JQ Annular Space or Vault Sensor. Model: p ❑ Piping Sump/Trench Sensor(s). Model: Gk Piping Sump/Trench Sensor(s). Model: Z ❑ Fill Sump Sensor(s). Model: NZ 9LF111 Sump Sensor(s). Model: 708 ❑ Mechanical Line Leak Detector. Model: L3Mechanical 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: ❑ ither(specirla ui ment ty a and model in Section E on Pa a 2). ❑ Other(s ecif equipment ty a and model in Section E on Pae 2). Dispenser ID: l'-if y Dispenser ID; 7 4- M M Dispenser Containment Sensor(s). Model: A Dispenser Containment Sensor(s). Model: �% A ;Bear Valve(s). -Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 7 sr•-/b 1S) Dispenser Containment Sensor(s). Model: 2406 A Dispenser Containment Sensor(s). Model: 7-p L&Shear Valve(s). 6 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: 5 1 Dispenser ID: I/ f /Z JR Dispenser Containment Sensor(s). Model: W Dispenser Containment Sensor(s). Model: ®.Shear Valve(s). A 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 ofI the report;(check all ihal apple): 4systern ' -u arm history report Technician Name(print): - ,41 Signature: -- Certification No.: License.No.: 6 " Testing Company Name: _ Phone No.: Site Address: 3 3 Date of Testing/Servicing: eS Page I of 3 03101 Monitoring System Certification D. Results of Testing/Servicing