Monitoring System Certification Form
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4Appendix VI
(Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at )
MONITORING SYSTEM CERTIFICATION
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 separate certification or report must be prepared for
each 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 agency regulating UST systems within 30 days of test date.
A.
General Information
Facility Name: ________________________________________________________________________ Bldg. No.:___________________
Site Address: ________________________________________________ City: ________________________ Zip: ____________________
Facility Contact Person: ___________________________________________ Contact Phone No.: (_______)__________________________
Make/Model of Monitoring System: ________________________________________
Date of Testing/Servicing: ____/____/___________
B.
Inventory of Equipment Tested/Certified
Check the appropriate boxes to indicate specific equipment inspected/serviced:
Tank ID: ____________________________________________
Tank ID: ____________________________________________
In-Tank Gauging Probe.
Model: ____________________
In-Tank Gauging Probe.
Model: ____________________
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: ____________________
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: ____________________________________________
Tank ID: ____________________________________________
In-Tank Gauging Probe.
Model: ____________________
In-Tank Gauging Probe.
Model: ____________________
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: ____________________
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: ________________________________________
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).
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).
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.
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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): _________________________________ Signature: __________________________________________________
Certification No.: _______________________________________
License. No.: ________________________________________
Testing Company Name: _______________________________________________ Phone No.:(_______)_____________________________
Testing Company Address: ___________________________________________________________ Date of Testing/Servicing: ____/____/_____________
Monitoring System Certification
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