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MONi ING SYSTEM CERTIF)4�TION 1 Bv.411 Jurisdictions Within the State of Callfarnia duthori7,Cited: Chapter 6.7, Health and Stffety Cocic; Chapter 16, Division 3, Title 13, Califiu nia Code of Reguhitions • 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 to within the tank system owner/operator. The owner/operator must submit a copy of this form to the locales t to within 30 days of test date. A. General Information JUL 1 7 2008 Facility Name: 1' ' .-T -T Cp t Bldg.No.: �EeTy J Site Address: a-L4 e Ci y: R( Facility Contact Person: CyYl2h� Contact Phone No.:Gio Make/Model of Monitoring System:zN@A" T;5 /00/ Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicates eciric a ui meat ins ec[ed/serviced: Tank fD: ofe--61eJ (r'� Tank ID: 23 In-Tank Gauging Probe. Model: f2 e- D in-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: il/2 D Annular Space or Vault Sensor. Model: .0 Piping Sump/Trench Sensor(s). Model: 446 D Piping Sump/Trench Sensor(s). Model: D Fill Sump Sensolls). Model: D Fill Sump Sensor(s)., Model: H Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor. Model O Other(specify a ui meat a and model in Section E on Pae 2). D Other(specify equipment t e and model in Section E on Page 2). • Tank ID: E t° D f.t. Tank ID: EF In-Tank Gauging Probe. Model: "kD In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 14 D Annular Space or Vault Sensor. Model: 'F] Piping Sump/Trench Sensor(s). Model: /A,,C2 O Piping Sump/Trench Sensor(s). Model: (3 Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: )1 Mechanical Line Leak Detector. Model: IIJ {7 D Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Tock Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor. Model: D Other(specify equipment t e and model in Section E on Page 2). D Other(specify equipment t e and model in Section E on Pae 2). Dispenser ID: I"-- 72 Dispenser ID: Dispenser Containment Sensor(s). Model: J✓S D Dispenser Containment Sensor(s). Model: Shear Valve(s). D Shear Valve(s). D Dispenser Containment Float(s)and Chain(s). D Dispenser Containment Floats)and Chain(s). Dispenser ID: 2 if Dispenser ID: Dispenser Containment Sensor(s). Model: /.f I.S D Dispenser Containment Sensor(s). Model: Shear Valve(s). D Shear Valve(s). D Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Choin(s). Dispenser ID: Dispenser ID: D Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: D Shear Valve(s). D Shear Valve(s). ODis enser Contai:unent Float(s)and Chain(s). ❑ Dis enser Containment Floet(s)and Chain(s). -If the facility contains more tanks or dispensers,copy this form. Include infarm,�-ayon for every,tank and dispgn�er atthe facility. tryttJ--, ctJc�6, MUQ C. Certification - I certify that the equipment identified in this document was inspected/se 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 attach d a copy of the report;(check all that apply): ❑S �r�o�e r•D,Alarm hlstOry re ort Technician Name(print): Signature: iX1I � 6Y�-E/1 w�� Certification No.: ( )Io l License.N�(� —/)-q-�5 ,,//, f Testing Company Name: nrT)A �P ST PhonJ eNo.:( o9 _ /;V4-00 ?- Site Address: Date of Testing/Servicing:_/_/ Page 1 of 7� - 03/01 Monitoring System Certification A Results of Testing/Servicing SJc