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`- MONI�RING S�TE�E�F&TION 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, Gl *6N*9flgro Regulations rht fl �,. EIFAA This form must be used to document testing and servicing of monitoring equipment. A separate certification) r.7&ddkt';/Em (be Prepared for each monitoring system control panel by the technician who performs the work. A copy of* gtust pbe�p�rovided the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency r l iRg >RXs/er within 30 days of test date. JGG A. General Information Facility Name: J I '7 *& 02&&A. Bldg.No.: ttzlg Site Address: r_/ . 1 City: "ftyflawZip: Facility Contact Person t �[[A m Contact Phone No.:( 71 _) Make/Model of Monitoring System: Date of Testing/Servicing: LI—/ffL/GL B. inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a ui ment inspected/serviced,: Tank ID: Tank ID: 8 In-Tank Gauging Probe. 0 In-Tank Gauging Probe. d 6 Annular Space or Vault Sensor. ` n 46 Annular Space or Vault Sensor. 0 Piping Sump/Trench Sensor(s1. Piping Sump/Trench Sensor(s). El Fill Sump Sensor(s). Cl Fill Sump Sensor(s). If Mechanical Line Leak Detector. t 3 Cl Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. V0 Electronic Line Leak Detector. V Tank Overfill/High-Level Sensor. tZ 36 3 aw • Tank Overfill/High-Level Sensor. ❑ Other(specify equipment[)2e and model to Section E on Page 2). ❑ Other(s ecif a ui ment tyee and model in Section E on Pa e 2 . Tank ID: _ Tank to: a In-Tank Gauging Probe. 46 In-Tank Gauging Probe. 41 Annular Space or Vault Sensor. 9 Annular Space or Vault Sensor. ` ,� 19 Piping Sump/Trench Sensor(s). Piping Sump/Trench Sensor(s). ❑ Fill Sump Sensor(s). �-Q IJ Fill Sump Sensor(s). Mechanical Line Leak Detector. _— 9&Mechanical Line Leak Detector. 94 3 ❑ Electronic Line Leak Detector. J ❑ Electronic Line Leak Detector. I;Tank Overfill/High-Level Sensor. V Tank Overfill/High-Level Sensor. r ❑ Other(specia a ui ment type and model in Section E on Pae 2). ❑ Other(specify equipment t 42 e and moael in Section E on Page 2). Dispenser ID: Dispenser1l), V, L ! Dispenser Containment Sensor(s: 8 Dispenser Containment Sensor(s).Wal ❑ Shear Valve(s). Awala� ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s) ❑ Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: i♦ Dispenser Containment Sensor(s). '*' ' Dispenser Containment Sensor(s). = ❑ Shear Valve(s). Aau b`u ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain s). C3Dispenser Containment Finials)and Chain(s). Dispenser ID: Dispenser ID: FE 10 Dispenser Containment Sensor(s). / : il Dispenser Containment Sensor(s).Sit W LJ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). i ❑ Dis enser 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, 1 have also attached a copy of the reppqqi-4(check all that app)IK- ■ System set-up l] m hi pry report Technician Name(print): n�64 / dl Signature: v Certification No.: _ License.No.: Testing Company Name: r " U Phone No NL/—/33 Site Address: Date of Testing/Servicing:�14—I� Page I of 3 03/01 Monitoring System Certification