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u u. Z/IC-,L-L)) 1--or I_! c Gv.-1/l Juriseliclions M'ithin the,S'lale nf'C alilbrniu 4k"4 Authori/v C'itee Chapter G.7, I-1 clhh andSake Code; C'htgver 1G, Dirision 3, Title 23, Culiyaria 1 T This form must be used to document testing and servicing of monitoring equipment. A separate certific ion Dr.re Host be prepared for each monitoring system control panel by the technician who performs the work. A copy of thi t AuS4 b vided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local aml •t �tul�.0 $yes nes within 30 days of test elate. ViKU1V�� t_I f fYAIf A. General InformationPERMIT/SERVICES Facility Name: I'TOF C'DI Cel l glZb Bldg.No.: Site Address: I33I S. LA A M Lh1 `i� City: o U 1 Zip: �5Z'Tz Facility Contact Person: TFAtA 1-5 . Contact Phone No.:( Zo ) --(G x 2(di0 Make/Model of Monitoring System: VIDE e3--T I r-S-�ate of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a i ro wiate boxes to indicate specific equipment ins ec ted/s a rV tela: Tank ID: P-3* M A 11,4 FTannk_TID: DIIn-Tank Gauging Probe. Model: I ank Gauging Probe. Model: Annular Space or Vault Sensor. Model• t_ ' O Annular Space or Vault Sensor. Model: Zo Piping Sump/Trench Sensor(s). Model: 2' 4 Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model: RZ-000 A Mechanical Line Leak Detector. Model: 5-rP-ML.0- -p ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment tye and model in Section E on Page 2). ❑ Other(s ecify e ui ment type and model in Section E on Pae 2). Tank ID: tsr� Tank ID: A5-M b I i.- �l In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 416 Annular Space or Vault Sensor. Model: Zo &Piping Sump/Trench Sensor(s). Model: X Piping Sump/Trench Sensor(s). Model: ZGg ❑ 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: (L Tank Overfill/High-Level Sensor. Model:6FW&T SftoS ❑ Other(specify a ui ment type and model in Section E on Page 2). ❑ Othe� r� (s ecify e ui ment a and model in Section E on Page 2). DispehserID: I 'f Z CiA!5 4- Ate`�Ct-- Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser 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). ❑ Dispenser 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 Contaiimtent Floats)and Chain(s). ❑ 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 reports,I have also attached a copy of�the report;(check all that apply): 09 - se -up 99 Alarm history report Technician Name(print): '7rH1�1, Signature: Certification No.: '42e -& 52� 3a7 —UT Certi 1�$3 License. �37-L #Qyt _1&.7l Testing Company Name: A:Wo-T DA cs r- Phone No.:W9 _)W-/— d/12, Site Address: 1 331 5 . qp'm I--IIS( Date of Testing/Servicing: Page I of 3 03/01 Monitoring System Certification A Results of Testing/Servicing