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