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wt- °` M04dTORING SYSTEM CERTMCATION For Use Bir AU Jurisdiclions Within the Smte of California AuthorityCited: Chapter 6.7, Heahh and S'gjety Code; Chapter/6, Division 3, Title 23, Cn/ifi�s»a C�bl� 0hrlioas � This form must be used to document testing and. servicing of monitoring equipment. A separate c 'on or re rt must be prepared for each monitoring system control panel by the technician who performs the work. A cop be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agrM4C '08T systems within 30 days of test date. V /9,grMFNr A. General Information Facility Name: '�J�J Q , �,,, Bldg.No.: Site Address: ! /t!"F0 l City: ZDi Zip: o2p 6-- Facility J'Facility Contact Person: bieJ^1 Contact Phone No.: Make/Model of Monitoring System:—TdLdh ,�_� zmL Date of Testing/Servicing: —IrD-2:7-P� B. Inventory of Equipment Tested/Certified Check the appouariate boxes to indicate specific ui ment ins Miceli 1Tank ID: /Y� ,� X11) Tank to: U In-Tank Gauging Probe. Model: Yh . LJ In-Tank Gauging Probe. Model: L3 Annular Space or Vault Sensor. Model:JI�X4 . LJ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Ll Mechanical Line Leak Detector. Model: 4'jyeO Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 13 Tank Overfill/Nigh-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Pae 2). ❑ Other(specify equipment t and model in Section E on Pae 2). Tank ID: Z2t f^lyse1ia6 Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: Wiz5k ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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: 0 Other(specify equipment t e and model in Section E on Pae 2). O Other(s ci a ui ment type and model in Section E on Pa a 2). Dispenser ID: � � z Dispenser ID: ❑ Dispenser Containment Sensor(s). Model:_ 115 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). U Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: FU ❑ Dispenser Containment Sensods). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis nser Containment Floats)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Disperser Containment Sensor(s). Model: - ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include inimmatio or everyv tank and dispenser ail fad ity. C. Certification - 1 certify that the equipment identified in this Ao eat was r pe to / r 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,l have also attach d a copy of rhe report;(check all that app&): ❑ Sy m,�y-'�lt-upg ❑Alprm history report Technician Name(print): �e n. /y;ml"n Signature: Gam Certification No.: License.No.: 90 ,l Testing Company Name: Phone No.:(�Og �ry4'O 1Id?_ Site o?- Site Address: Date of Testing/Servicing: Page 1 ofd 03/01 Monitoring System Certification D. Results of Testing/Servicing