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MONITORING SYSTEM CERTIFICATION 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, California code jltgjia6otZ004 This form must be used to document testing and servicing of monitoring equipment.A separate certificationr t RWM diFdlalr�hl for each monitoring system control panel by the technician who performs the work. A copy of this form mu Q'� Ijt@�k system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating systems within 30 days of test date. A. General Information p Facility Name: ( * o to t+!-f/Lt4 1 VI A 2k d PC h C E Bldg.No.: Site Address: l7gr VI/&l` c1-1 <R WAN City: STaCh'7�A1 Zip: itS2C a Facility Contact Person: / j T Contact Phone No.: ( Z a"3 ) '''37i -/7S 9 Make/Model of Monitoring System: G 1( J3A/1Co (_Ne- Date of Testing/Servicing: 1_15- 1 O B. Inventory of Equipment Tested/Certified Check the appropriate tones to indican specific equipment ins ted/ser.iced: Tank ID: -01 - Zo,yyl 7 L..�-c c.� .� K7 Tank ID:�2- / ou cco j) / In-Tank Gauging Probe. Model: ORO ZL '/32rL1 • In-Tank Gauging Probe, Model: AO•LES/ 20?./ 11 Annular Space or Vault Sensor. Model:?AC Z Sq///F*-r.+OO ■ Annular Space or Vault Sensor. Model Mt Z 51.)It#4 VIL W Piping Sump/Trench Sensor(s). Model: LOAC Z010P4W/u ■ Piping Sump/Trench Sensor(s). Model: fAy 4592.Docn to O Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: 6 Mechanical Line Leak Detector. Model: - FX I ■ Mechanical Line Leak Detector. Model: A?. J, FILI U O Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: • Tank Overfill/High-Level Sensor. Model: T Tank Overfill/High-Level Sensor. Model: OR-C-0 7yRE Fi-rP O Other(specify ui ment type and model in Section E on Pae 2). O Other(specify equipment type and model in Section E on Pae 2). Tank ID: Tank ID: O In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: O Annular Space or Vault Sensor. Model: O Piping Sump/Trench Sensor(s). Model: O Piping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: O Mechanical Lice Leak Detector. Model: O Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Tank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: O Other(specify ui ment type and model in Section E on Pae 2). O Other(specify ui ment type and model in Section E on Pae 2). Dispenser ID: it / Z Dispenser ID: A 3/¢ ■ Dispenser Containment Sensor(s). Model: PAC 1-9 SdOCyi l 8 Dispenser Containment Sensor(s). Model: P90>g_19 60 i/ ■ Shear Valve(s). ■ Shear Valve(s). O Dispenser Containment Float(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: N Dispenser Containment Sensor(s). Model: Pq0 S9ji-4000!i ■ Dispenser Containment Sensor(s). Model: PAC 515-op&' / ■ Shear Valve(s). ■ Shear Valve(s). O Dispenser Containment Float(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: ;? 14Z 12- a 2- w Dispenser Containment Sensor(s). Model: A40 S 9SSO ■ Dispenser Containment Sensor(s). Model: P?�.J'95�•. :l ■ Shear Valve(s). * Shear Valve(s). UDispenser Containment Float(s)and Chain(s). O Dispenser Containment Floats)and Chain(s). cif 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 have also attached a copy of the repg ft;(check all thQt apply): 8 System set-up 1 AI history re{�rt Technician Name(print): Ku5S27-L Ko 4.,VL5 Signature: (�.c-4------ Certification No.: 4200 -O o -- Z6 S- 7- License.No.:. 957 - /Z S Z Testing Company Name: sa A1,04-rlf Phone No.:��)Z75-- 6 &6-1 Site Address: C• M. P / 49 It! CR4x-rc7'tydA*+ <7?CA.Te/Jj Date of Testing/Servicing: UN-036-1/4 Page 1 of 3 Rev,0610"1 NwN.unidO org