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MONihll,,,,ORING SYSTEM CERTIFI%oATIllp 1 For Use Ry.4/1 Jurisdictions Within the State of California Anthor/ty Cited• Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of 9Reg99ullapptiions This form must be used to document testing and servicing of monitoring equipment. A separate cert$cBation'Sr'vLntlYdrt must be prepared for each monitoring system control panel by the technician who performs the work. A cop y&'IR fM ry to to the tank system owner/operator. The owner/operator must submit a copy of this form to the local a� '� �� q ystetns within 30 days of test date. GGG A. General Information Facility Name: RNc.1-�o l 1 �I L(,�L Bldg.No.: Site Address: 6 ZO n'5 . �.0K9EC LIS City: L inti t Zip: Facility Contact Person: G/La-efLY Contact Phone No.:( 7o7 )$58_ p/b/ Make/Model of Monitoring System: V Kf pE12 t2oo-1 5-350 Date of Testing/Servicing: C91 0:7 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific a ui ment inspected/serviced: T pk ID: Tank ID: ,PT -Tank Gauging Probe. Model:�F�6t� _ ❑ In-Tank Gauging Probe. Model:- nular Space or Vault Sensor. Model 4 Zc> ❑ Annular Space or Vault Sensor. Model: P' ing Sump/Trench Sensor(s). Model:� ❑ Piping Sump/Trench Sensor(s). Model: ill Sump Sensor(s). Model: 2.0g ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FX- IV ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Taiilc Overfill/High-Level Sensor. Model: ❑ Other(specify aqui ment t e and model in Section E on Page 2). ❑ Other(specify a ui ment t and model in Sectt n E on Pa a 2). To k ID• 1 O�--"f Tank ID: In-Tank Gauging Probe. Model: 61 1 ❑ In-Tank Gauging Probe. Model: �❑ nular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ! ing Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: lO 1 Sump Sensor(s). Model: 8 ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: X'1 ❑ 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[ e and model in Section E on Page 2). ❑ Other(specify a ui ment type and model inSecd E on CPa2e . Djw�'Spenser ID: I `/ Z Dispenser ID: A spemer Containment Sensor(s). Model: 8 LI Dispenser Containment Sensor(s). Model: EI Shear Valve(s). L3 Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). �DyppPeaser ID: �' Dispenser ID: e .17�Dispenser Containment SensoKs). Model.* f3 ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). - ❑ Dispenser Containment Float(s)and Chain(s). Dis�pPenser ID: Dispenser ID: ot3,Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: �U Shear Valve(s). ❑ Shear Valve(s). LIDispenser Containment Float(s)and Chain(s). 1 ❑ Dispenser Containment Float(s)and Chain(s Nf 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 equ ent. For any equi ent capable of generating such reports,l have also attached a copy of thf repor (check a//that app/r): ystem se - Alarm history report Technician Name(print): �aNE (V =C13 Signatur Certification No.: /15-3 n6' 00 � License.No.: Testing Company Name: 4 `o1ZOA —%ES7 Phone No.:(. 4�b-1 '7 ._ d// (— Site Address:. • G't4k-0-d�tC_k_rkc� L Date of Testing/Servicing: ( 140-7 --- Monitoring System Certification Page I off 03/01 D. Results of Testing/Servicing