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ONI ORING SYSTEM CERTIFY"A TI NR°DCDUED For Use By All Jurisdictions Within the. ;r Cal iJorniu Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16; I' -Sion 3, Title 23, CuliJnrniu Corlc�4R �ulutiun.� .1H1V 2005 This form must be used to document testing and servicing of monitoring equipment. A separate certifica 'on or report must be prepared For each monitoring system control panel by the technician who performs the work. A copy of this f .4QApLMNc60Ujj-ryk system owner/operator. The owner/operator must submit a copy of this form to the local agency re R � Tt4sth1[}[ ILEO days of test date. A. General Information Facility Name: J, Z Bldg. No.: Site Address: City: "® _ Zip: Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: Z,(,t, Date of Testing/Servicing: ZZ/ Z.D/041 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: Tank ID: z, •� ✓ )KIn-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: ykj 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: echanical Line Leak Detector. Model: echanical 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(s ecif equipment t and model in Section E on Pa de 2). ❑ Other(s ecif equipment t e and model in Section E on Page 2). Tank ID: dtieA Tank ID: min-Tank Gauging Probe. Model: _ ❑ In-Tank Gauging Probe. Model: fly Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model': D Piping Sump/Trench Sensor(s). Model: A Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model: loo ❑ 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: ❑ Others ecif a ui ment tyZ and model in Section E on Pa e 2L ❑ Other(s ecif a ui ment ty2e and model in Section E oil Pa>e 2). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). ,'Shear Valve(s): ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: VAXt4Q8P ❑ 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). Dispenser ID: Dispenser ID: 9� �-- Dispenser Containment Sensor(s). Model: ft Dispenser Containment Sensor(s). Model: Shear Valve(s). XShear Valve(s). ❑Dis enser Containment Floats 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 A 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;(c eck a9hat ap I): ystem set-up Alar istory re ort Technician Name(print): grrg► Signature: Certification No.: .7 License.No.: Testing Company Name: Phone No.:("V ) -,CFzt5 Site Address:' Date of Testing/Servicing:/2_/Z0/CrV UN-036-1/4 Page 1 of 3 Rev.06/04/01 www.unidocs.org