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MONITONG SYSTEM CERTIFICONON ` For Use By. /1 Jurisdictions Within the Slate nf'CaliiJb0,ia Authority Ciled: Chapter 6.7, Health and.Snfeo,Cocle; Chapter 16, Division 3, Title 23, California Coilz 0/7�c rrrlertirarzl ,..�� This form must be used to daClnllent testing and servicing of monitoring equipment. A se orate certific-rttap e to ()rt niiis 'e Lire arecl for each monitoring system control ane, by the technician who performs the work. A copy of this form must Ir-:proviclecl to the tank system owner/operator. The owner/operator must Submit a copy of this Form to the local agency regulating I ST systems within 30 days of test date. A. General Infor ation Bldg.No.: Facility Name: r r``S r�' Site Address: �� S City: C, •r'-C�'� .Zip: Facility Contact Person: T�S`� �°� ; �,��,� Contact Phone No: Zo �) Z 2 Make/Model of Monitoring 5ysterrt: 1 J Date of Testing/Servicing:�/�/ `F B. Inventory of Equipment Tested/Certified Checl,thea ro lriate boxes to indicates eciric a ui nient ins ected/serviced: Tank ID: �` • Tank ID: CAA All In-Tank Gauging Probe. Madel: l �1 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor_ Model: 'A J 0 Annular Space or Vault Sensor. Model:, H 4 Piping Sump/Trench Sensor(s). Model: 2U Piping Sump 1 Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model; ❑ Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model: L Ic��' 0 Mechanical ect onic LineLine Leak Detector. ctor. Model: ❑ Electronic Line Leak Detector. Model ❑ 'Tank Overfill/High-Level Sensor. Model: ❑ Tank-Overfill l High-Level Sensor. Model: ❑ Other(specikaquipment type and model in Section E on Page 2). ❑ Other(specify a ui ment a and model in Section E on Pace 2). Tank ID: - ,+� Tank ID: i In-Tank Gauging Probe. Model: ❑ In-Tank Gauging('robe. Mode]: - + ❑ Annular Srce ar It Sensor. Model: - WAnnular Space or Vault Sensor. Model: I R p Piping Sump I Trench Sensor(s), Model: 2C% � ❑ Piping Sump 1 Trench soy Model: ❑ Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ill Mechanical Line Leak Detector. Model: -� it �- ❑ Mechanical Line Leak D cto . Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak etectnr. ode]: ❑ Tank Overfill l High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Otlier(specify e ui ment tv9�e and model in Section E on Page 2). ❑ Other(specify e ui merit tY e and model in Section E on Pae 2). Dispenser ID:_ Dispenser ID: Dispenser Containment Sensor(s). Model: "� _ 1�.Dispenser Contairunent Sensor(s). Model: +�{ Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chaiit(s). Dispenser-ID: Dispenser ID: ❑ Dispenser Containment or(s . Model: ❑ Dispenser C�ntadnrnent,e �Jnd adel:O Shear Valve(s). ❑ Shear Valve ).❑ Dis enser Containment Float(s),and Chain(s). ❑ Dis enser Cntainmen oat(s) ain(s). Dispenser ID: Dispenser ID: :1" Dispenser Containment Sensor(s). Model: ` _ Dispenser Containment Sensor(s). Model: Shear-Valve(s). Z Shear Valve(s). :]Dispenser Contairunent Float(s)and Chain(s). ❑ Dispenser Contaimnent Floats)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,I Ir:ive also attached a copy of the report; (check all that apply): ❑ Sy em et-ftp El Alarm histor report ,_D Technician Name(print): Felix Ramirez Signature: Certification No.: �� License.Na.: OTTL#08-1740 ICC#5273934 T 17 Testing Company tName: a��® G Q Phone No.: Site Address: ` 1�t4 �1 Date of Testing/Servicing: Page I of3 03111 Monitoring System Certification D. Results of Testing/Sel-vicing