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APR 2 . parr Appendix Vi (Copies of Monitoring System t attification form and UST Monitoring Plot Plan available at htto:Uwww w terboards.°bov)'``''' NII 1141TORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited.Chapter 6.; Health and Safety Code;Chapter 16,Division 3, Title 23, California Code of Regulations This form must be used to docume- testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring system control par t by the technician who performs the work..A copy of this form must be provided to the tank system owner/operator. The owner/operate-- lust submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. Generallnfomtatie Facility Name: _ `. mcBldg.No.: Site Address:. c_-t =; }f �— City= J Zip: p Facility Contact Person: t--5': :!m Dal Contact Phone No.:L__2 C2; VG Make/Model . ,of Monitorinj System: �, EUS .•.m Date of Testing/Servidng: B. Inventory of Equipment Tested/Certi:i, f Check thea ro riateboxes to find ate specific a ui tttent ins ected/serviced: Tank ID: Tank ID: in-Tank Gatrgin g Probe. 10, let: 111C to-Tank Gauging Probe. Model: Annular Space or Vault.Sensor. kl' let: Annular Space or Vault Sensor. Model: _ Piping Sump/Trench Sensor(s). N11 le.: Piping.Sump/Trench Sensor(s). Model:. G1 C Fit Sump Sensor(s). UI1 Is: 0 FII Surnp Sensor(s). Model: 1%e-Mechanical Line Leak Detector, Ira I s: X Mechanical Line Leak Detector. Model: .[7 Electronic Line Leak Detector. F t le: 0 Electronic line Leak Detector. Model: C Tank Overfill/High-Level Sensor. PC ie.: 0 Tank Overfill/High-Level Sensor. Model: C Others ent and mode;i S tion E on Pa 2). 0 Other a ui ent t and model in Section E on Pe 2). T nklD _ TankID: In-Tank Gauging Prue. laic el: in-Tank Gauging Probe. Model:Annular Space or Vault Sensor. Mc el: . Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s} IV'C el: ®��®® Piping Sump./Trench Sensor(s). Model: Fill Sump Sensor(s). Mc el:_ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Mc el: Mechanical Line Leak Detector. Model: C Electronic Line Leak Detector. Mc el: ❑ Electronic Line Leak Detector. Model: [C Tank Overfill J.High-Level Sensor. tvi: at: 0 Tank Overfill d High-Level Sensor. Model: C .Other s ed u' ent fte and model 4 Section E on Page 2. O Other a u ent a and model in Section E on Pa Lie 2). Dispenser ID:,-LIP la Dispenser ID: L. Dispenser ContairAi5int Sensor(s). Wh; at Dispenser Containme t Sensor(s). Madel: �t:.Shear Valve(s). BGShear Vatve(s). C Di nser Containment Floatfpl and Chain }` D D riser Containment Floats and Chain(s), Dispenser ID: l.•_ Dispenser ID: PC. Dispenser ConiainrnrReensor(s). M) at:� 0 Dispenser Containment nsor(s). Model: Shear Vaive(s). �Shear Va"s). C .Dis enserContairrnent-Float(s)and Chaim }. 0 Dispenser Containment Float s)and Chain sl. Dispenser ID: /tom Dispenser ID: C Dispenser Cont1 V149 ain +ent Sensor(s). Mu :I: G Dispenser Containment ensor(s). Model: >e,Shear Valve(s). X Shear Valve(s) ''z Dispenser Containment Floats and Chain _ 0 Disnenser Containment Float(s)and Chain(s). ,if the facility contains more tanks or dispenser c.py this form. Include information for every tank aril dispenser at.the facility. C. Certification - 1 certify that the equi meat identified In ills document was Inspected/serviced in accordance with the manufacturers' guidelines...Attached to this Certiticab n is information(e.g.manufacturers'checklists)necessary to verify.that this Information is correct and a Plot Plan showing the layout of i onitoring equipment. For any eqpWent capable of generating such reports,I have also attached a copy of.the.report;(check a/!•that appjP O.System set-up . O AI eport TectinlctanName(prirtt}:, '� I� _ Sigreture: Certification No_: Mi �t� S C se.No.: Testing Company Name: Phone No.:L dc�rI - Testing Company Address: o'S3 { X�OA�j5 �� 3 Date of T�tirx}lSa icing: 141 Monitoring System Certification Page'!of 4 12107 1 2/21/07 I 'd ZbE9T9b60Zi sio4oeW00 Ay e4t13 e9tsG0 TT 92 .add