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MONITORING SYSTEM <br /> • ' SYSTEM CERTIFICATI <br /> F 'IseBy,1/ JurisdictionsFl?N7ir7NreStateofCc. <br /> nia <br /> gztthoriry Cited Chafer 6.7, t, h and Safety Code; Chapter/6, Division 3, Tit,, r3, California Co eo119. �s � <br /> This form mast be used to document testing and servicing of monitoring equipment. A separate certificati <br /> prepared for each monitorings system control panel by the technician who performs the work. A copy of this form must e prove ed to <br /> the tank system owner/operator. .The owner/operator must submit a copy of this form to the local agency t I o T s}stems <br /> within 30,days of test elate. AN jft&Y�T s6N7Y <br /> ENVIRONMENTAL <br /> A. General Information HEALTH DEPARTMENT <br /> Facility Name: Zocl; ygZ1 <br /> Bldg.No.: <br /> Site Address: i_%.r t Si •HAS L AJ City: 1.-CA JI• Zip: <br /> Facility Contact Person:��,•�.a'z-1 Contact Phone No.: ( 'Zcl <br /> Make/Model of Monitoring System: Ve-eA ,- �sj: (,j - Tj Date of Testing/Servicing: <br /> B. Inventory of Equipment Tested/Certified <br /> Check thea ppropriate boxes to indicates ecitic equipment ins ectedfserviced: <br /> T. k ID: TE) <br /> ank ID: jQ C, <br /> n-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: <br /> Annular Space or Vault Sensor. Model:_ Annular Space or Vault Sensor. Model: Y40 <br /> Piping Sump/Trench Sensor(s). Model• piping Sump/Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: Fill Sump Sensrn(s)• Model: <br /> Mechanical Line Leak Detector, Model: y Mechanical Line Leak Detector. Models%'7�--,�YJ❑ Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify e ui ment ty a and model in Section E Other(s ecify e uipment t eand model in Section E on Pa a 2). <br /> TanlclD: .� Sy� 1ankID:P1n Tank Gauging Probe. Model:_ In-Tank Gauging Probe. Model: <br /> Annular Space or Vault Sensor. Model: 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:❑ Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: Tank Ovea /High-Level Sensor. ' <br /> ❑ Other(s ecify equipment ty e and model in Section E on Page 2). ❑ Other(specifyequipment type and model in Section Eton Page <br /> /J <br /> Di• enser ID: — 4;,14,C ,r ([Ail I Dispenser ID: <br /> Dispenser Containment Sensor(s). Model: 4" El Dispenser Containment Sensor(s). Model: <br /> Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Floats)and Chains) ❑ Dis enser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s)' <br /> LEI Valve(s). <br /> ❑ Dis.enser Containment Float(s)and Chain(s)• ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑Dis enser Containment Floats)and Chains) 1 ❑ Dispenser Containment Float(s)and Chain(s). <br /> ,Ifthe I'acility contains more tanks or dispensers,copy this fbri Include information for every tank and dispenser-it the facility. <br /> Air one—IA-v <br /> C. Certification - 1 certify that the equipment idet elft icd in this document was inspected/serviced in accordance with the <br /> manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this <br /> information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such <br /> reports,1 have also attached a copy of the report;(cheek aft thrd,rppiy): 0system se - P J�Alarm history report <br /> Technician Name(print):-� �yi'o f;n fCf�i,' Signature: J <br /> Certification No.: =w? 52 x'73-ar <br /> 3`�l�7Jr License.No.: Ll�' At t� —/'7 3 f <br /> Testing Company Name: 14Mr aA 725 T Phone No.:� <br /> Site Address: 13=�i ,t", �/ss�,rs►, L rt Date of Testing/Servicing: <br /> 12- <br /> Monitoring <br /> 2Monitoring System Certification Pa!;e 1 uta <br /> 1!3/111 <br /> } <br /> r'. .Pesldts Ck� rl t.''SQ'I:BL'rM/"+ l C&4 6Gl rr <br />