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+ MONfoo6RING SYSTEM CERTIFIwiOTION For Use By AH Jnrdsdiclions I17117in Me Slide o/'Calybrnin D + Aadioriq,Cited:C'hapler 6.7, Health and Si+f r),Code; Chopler 16, Division 3, Tille 13, Cellifornia('ode aJ'Re/gtuln � This form must be used to document testing and servicing of monitoring equipment. A separate certific on oi" must be prepared for each monitorine system control oanel by the technician who performs the work. A copy of thisTOr be prvU the tank system owner/operator. The owner/operator n11W sublliit a copy of this form to the local agency to systei{is within 30 days of test date. �r7 A. General Information /TjSFh'!//C�S�TFj Facility Name: ��I,ILILI Bldg.No.: Site Address: Z413 �. Alo/%osA 4a City: 5 o To Zi Facility Contact Person: �DA ✓/DI Contact Phone No.: ( >O`f ) !2&, Make/Model of Monitoring System: XtL,.�xJ o0 1 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate 99ecific a ui ment inspected/serviced: Tank ID: D/AE Tank ID: 25 In-Tank Gauging Probe. Model: Mph O In-Tank Gauging Probe. Model: c &Annular Space or Vault Sensor. Model: k LS ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: to ws ❑ Piping Sump i Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s). Model: 2( Mechanical Line Leak Detector. Model: STP-MLD• h ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: L3 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: D I E 3 Tank ID: 1.4., In-Tank Gauging Probe. Model: MAoa ❑ In-Tank Gauging Probe. Model: pt Annular Space or Vault Sensor. Model: IA4,% ❑ Annular Space or Vault Sensor. Model: �1 Piping Sump/Trench Sensor(s). Model: LA" Q Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: JL Mechanical Line Leak Detector. Model:dVir-Mut -b ❑ 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 equipment a and model inWonft2e2). Dispenser ID: / 'Y Z Dispenser ID; * Dispenser Containment Sensor(s). Model: IArb ❑ Dispenser Containment Sensor(s). Model: R Shear Valve(s). 13 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: ate{yDispenser ID: fz A Dispenser Containment Sensor(s). Model: Ltt+S ❑ Dispenser Containment Sensor(s). Model: li Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). I O Dispenser Containment Float(s)and Chain(s). Dispenser ID: I Dispenser ID: ❑ Dispenser Containment Sensor(s). Model' A ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Q Shear Valve(s). UDispenser Containment Float(s)and Clnain(s). ❑ Dibrenser 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 fac• ty. C. Certification - 1 certify that the equipment identified in this document wits 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 Phan showing the layout of monitoring equipment. For any equipment capable of generating Stich reports,l have also attached it copy of the report;fc6eck all that apply): lkSyat7 _ A Alarm history report Technician Name(print): 7-4pie ;�.i, o Signature:J Certification No.: ��zve zw 33a 7 —UT zh?.3 License. 1)7r, ## W ./&.2b Testing Company Name: AEOCOA _ TeSr Phone No.: Aa2 ) _-Vt1 - p/",p, Site Address: ZYS l ri_ I-11AlL/P65s - Date of Testing/Servicing: I- Page 1 of 3 03/01 Monitoring System Certification R. Results of Testing/Servicing