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r REC OVED MONITORING SYSTEM CERTIFICATION tap 3 12002 For Use By All Jurisdictions Within the State of California f ' et�t'ps®��At7tE�,�H Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16,Division 3, Title 23, Cali or ' �T SERV" rPdr fbbo ICES This form must housed to document toting and servicing of monitoring equipment.a separate certificatio must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General InformatioQ� f/ Facility Name: ��-� t r'`-^-' B ld'g.No.: Site Address: Irrj� City: 56ro ' l Zip: Facility Contact Person: MQ�l k n Contact Phone No.: ( �y �'�•�r Make/Model of Monitoring System: �� Rom T(S ASO Date of Testing/Servicing: 4 /tea c ire B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serAced: 1 Tank ID: Tank ID: V 0 In-Tank Gaugin robe. Model: 0 In-Tank Gauging Probe. Model: Nr Annular Space or Vault Sensor. Model:��{'sq0-42U Annular Space or Vault Sensor. Model:" CM15W 4ZU §e Piping Sump/Trench Sensor(s). Modell g436D'-X8 8 Piping Sump/Trench Sensor(s). Model. AT Fill Sump Sensor(s). Mode1:1Q4'S5'sD•'-NI>3 9Fill Sump Scnsor(s). Model:')Cey's _ _. ' Z0016 Mechanical Line Leak Detector. Model: qQt-13,61cm J&Mechanical Line Leak Detector. Model: gCD�rs� 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment t e and model in Section E on Page 2). 0 Other(specia equipment tv a and model in Section E on Page 2). Tank ID: Tank ID: 0 In-Tank Gaug g Probe. Model: 0 In-Tank Gauging Probe. Model: r,K Annular Space or Vault Scnsor. Modell44� 0 Annular Space or Vault Sensor. Model: R Piping Sump/Trench Sensor(s). Modc1:1445 2) Cl Piping Sump/Trench Sensor(s). Model: JET Fill Sump Sensor(s). Modell 43�' 0 Fill Sump Sensor(s). Model: ,»Mechanical Line Leak Detector. Model: I C.lY Y? CI Mechanical Line I-eak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment ty a and model in Section E on Page 2). 0 Other(s ecify equipment ty a and model in Section E on Page 2). 40 Dispenser ID: —Z Dispenser ID: �Ll XDispenserContainmentSensor(s). Model: 3'50"3 l J� Dispenser Containment Sen'sor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Flont(s)and Chain(s). 0 Dis enser Containment Float(s)and Chain(s). etspewer ID: y'10 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: � t Jf Dispenser Containment Sensor(s). Model054 O'3Z.t 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Di enser Containment Float(s)and Chain(s). Dispenser ID: 4`l Dispenser ID: l t`U— R Dispenser Containment Sensor(s). Model: t7D'S2l B.e Dispenser Containment Sensor(s). Model: &OW_n k 0 Shear Valve(s). 0 Shear Valve(s). Obis enser Containment Float(s)and Chain(s). 0 Dispenser 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 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 re ,I ve also attached a copy of the report;(check all that apply): 1�System set-up Alarm history repo Technician Name(print): rihni Fn f- Signature: Certification No.: .JL�—�01 �y License.No.: Testing Company Name:� Scott Co of California Phone No.:( gin ) RqS-7"I-R ,r -IRS Site Address: ��7 y�I,1 (lf5�V • Date of Testing/Servicing: 4 � � Page 1 of 3 03/01 Monitoring System Certification