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MONO ,R!NG SYSTEM CERTIFI*tTI011i R° ECE�V Eg) >q� Use f? All Jurisdielions Within theSlate of Califrrnio Aathorily 0lerl: Chapter 6.7, l-leallh and SafetyCade; C'hcrpler 16, Division 3, Ti/%23, California Code of Regulalionr JJ�� AY "00 This form must be used to document testing and servicing of monitoring equipment. A separate certificatiion or re3rr11 At be prepared for each monitoring system control pod by the technician who performs the work. A copy of thtssjfW(NM��ff{{��''p��ppyy�� c{• the tank system owner/operator. The ownere"perator must submit a copy of this form to the local agency within 30 days of test date. FFff VV t�Ct A. General Information t _ ` Facility Name: r I/�(�1V j' L ca) Bldg.No.: Site Address: ) C City: rl("C,yy�(,(� Zip: Facility Contact Person: �� Contact Phone No.:( 2.(� ) 52�- 7 Make Model of Monitoring System:Z NCC)1� `J l� (f7 Date of Testing/Servicing:0 0/oE B. Inventory of Equipment Tested/Certified C'heci,theappropriate boxes to indicates ecific a ui ment ins ected/serviced: Tank ID: QI, Tank ID: � )J In-Tank Gauging Probe. Model: Ml)(, - GT In-Tank Gauging Probe. Model: A(� ¢Annular Space or Vault Sensor. Model: F)S Annular Space or Vault Sensor. Model: S i Jd Piping Sump/Trench Sensor(s). Model l ILS Piping Sump/Trench Sensor(s). Model' I�Lc ❑ Fill Sump Sensor(s). Model: El Fill Sump Sensor(s)., Model: �'Mechanical Line Leak Detector. Model: L17 7_.000 g Mechanical Line Leak Detector. Model:Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 0 Tail:Overfill/High-Level Sensor. Model: ❑ Other(specify equipment ty a and model in Section E on Pae 2). ❑ Other(s eci a ui meat t e and model in Section E on Page 2). Tank ID: -� 1 Tan : �1 In-Tank Gauging Probe. Model: 1 114 G Q In-Tank 'ng Probe. Mod Annular Space or Vault Sensor. Model:�— ❑ Annular Space or It Sensor. odel: O Piping Sump/Trench Sensor(s). Model: ULS ❑ Piping Sanp/Trench Se Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). ode]: Jd Mechanical Line Leak Detector. Model:EV2 040 ❑ Mechanical Lit eak Detector. Mo e. ❑ Electronic Line Leak Detector. Made]: Q Electron' me Leak Detector. Model: ❑ Took Overfill/High-Level Sensor. Model: ❑ T verfill/High-Level Sensor. Model: ❑ Other(s eci a ui ment a and model in Section E on Page 2). ❑ Other(specify a ui ntent type and model in Section E on Pa a 2). Dispenser ID: 1 4 L Dispenser lD: 1 I R ❑ Dispenser Containment Sensor(s). Model: ULS ❑ Dispenser Containment Sensor(s). Model i) U Shear Valve(s). Q Shear Valve(s). ❑ Dispenser Containment Flont(s)and Chain(s). 13 Dispenser Containment Float(s)and Chain(s). Dispenser ID: s H Dispenser ID: ❑ Dispenser Containment Sensor(s). Model. UL El Dispenser Contaitvnent Sensor(s). Model: U ShearValve(s). ❑ Shear Valve(s). ❑ Dis enserContainment Floats)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: i Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: VLG ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Q Shear Valve(s). ❑Dis p enser Containment Float(s)and Chaims). ❑ Dispenser Containment Morris)and Chi..(s). •If the facility contains more tanks or dispensers,copy this form. Include information every tank pandd sp�enser' the facili yq C. Certification - ► certify that the equipment identified in this do Cal' sin;,L,I d/set4a (f ficEui l die�witn 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 nn equip tent capable of generating such reports,l have also attach d a copy of the report;(check n!!lhnr app/v): Sys in t-t � la im h report Technician Name(print): Signature: �} Certification No:: License.No.: /0 / Testing Company Name: n\ r5>A `Tp c,T Phone No.:( O9 4 �7ry -0f�o2- Site Address; a c��Z3 IV �,W t t RC1 Date of Festing/Servicing:D�,Qb f.� - Page I of] 03/01 Monitoring System Certification D. Results of Testing/Servicing 61