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MONITORING SYSTEM CER'I'I'ICA'I'YG§qJEC ,I5 VE D For Use B),Al/Jurisdictions 11 ithin the Stale(?f CcdiJurniu • t .4ulhorily Cited: Chap/er 6.7, Health and.$'dein C'ocle; C'hapler 16, Dirision 3, Til/c,33, Crtlijbrnia Coc%of Requlationr This form must be used to document testing and servicing of monitoring equipment..A separate certifCA Nn�r'Ire2009 Wrt r I, prepared for each monitorin system control Panel by the technician who performs the work. A copy 0MVIR 1NNIMP,1J F. the tank system owner/operator. The owner/operator must submit a copy of this form to the local a eirtw rt;,#4t� Mill to within 30 days of[est date. g rC �I cJfT�VJys ems A. General Information �- r Facility Name: Mo x21 q �n—r•1 eya.DN.:�, YA57 tj � t$ (Q p Bldg. No.: Site Address: l0876 N F� .99 7 city: �-rorr�tc►J zip: 9521Z Facility Contact Person: Contact Phone No.: (_2.p�_) 431 - I Make/Model of Monitoring System:�j�U 'Tr I ' Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Checl(the appropriate boxes to indicates ecific a ui ment inspected/serviced: Tank ID: SI Tank to: fGl.i Al hi-Tank Gouging Probe. Madel: M 61 lid In-Tank Gauging Probe. Model: 29 Annular Space or Vault Sensor. Model: or au e sac Model: ,rd Piping Sump/Trench Sensor(s). Model: Ut,) Piping Sump/Trunci Sensor(s). Model:- ❑ Fill Sump Sensor(s1. Model: EI Fill Sump Sensor(s). Model: 9 Mechanical Line Leal:Detector. Modeh K• I Asl Mechanical Line Leak Detector. Model: Fx-tJ 1J ❑ Electronic Line Leak Detector. Model: Model Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: - ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify�a qui ment type and model in Section E on Pa e 2). ❑ Other( ecify a ui meat t e and model in,Section E on Pa a 2). Tank ID: `•C 1 Tank to: O 61 In-Tank Gauging Probe. Model: MEi4 Aff In-Tank Gauging probe. Model: el Annular Space or Vault Sensor. Model: G(L5 ❑ Annular Space or Vault Sensor. Model: [d Piping Sump/Trench Sensor(s). Model 01-5 19 Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model GJ!Mechanical Mechanical Line Leak Detector. Model: 99Gd 200[7 151 Mechanical Line Leak Detector. Model: r-7X- t d ❑ Electronic Line Leak Detector. - Model: - ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tail:Overfill/High-Level Sensor. Model: ❑ Other(specify e ui ment t e and model in Section E on Page 2). ❑ Other(spoecifza ui mient Ly2c and model in Section E on Pa a 2). Dispenser ID: ( -V Z- Dispenser ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Contauunent Sensor(s). Model: A Shear Valve(s). Shear Valve(s). 4l Dispenser Containment Float(s)and Chain(s). Dis unser Containment Floats)and Chain(s). Dispenser ID: `f Dispenser ID: 7.i-$ ,Q Dispenser Containment Sensor(s). Model: I7 Dispenser Containment Sensor(s). Model: 46 Shear Valve(s). ZR Shear Valve(s). Ak Dispenser Containment Flont(s)and Chain(s). &Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: I] Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). I7 Shear Valve(s). ❑Dis enser Containment Floot(s)and Chain(s). ❑ Dis nser Containment Float(s)and Chain(s). "If the facility contains more to, or dispensers,copy this fame. 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 opr/the report,(check'alpha/apply): 781 System se - - Alarm history report Technician Name(print):=qag /i n�C+ Signature: Certification No.: //93 License.No: C &` � Testing Company Name: Site Address:/p878 Phone No.:�,' �__) — p//ten /!�, r/'hl�./ / l02 °t"2Y �� Date of Testing/Servicing: /0 Page I of 03/01 NlonitoringSystenl Certification A Results of Testing/Servicing