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MONI' :RING SYSTEM CERTIFI .TION w 1Q ' For Use By Al Jurisdictions Within the State of California Aathority Citeek Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Californi t r Is_ ;� /��i This form must be used to document testing and servicing of monitoring equipment. A separate certification or report iia ?bl e prepared for each monitoring system control panel by the technician who performs the work. A copy of this/ii•ip nji.%be rovided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating FJ. �yms y within 30 days of test date. EhViF: +,, P�f� �1J' hii_jti A. General Information t+'t(f/SEAIil��A" Facility Name: F00 y Zif SS Bldg.No.: ES Site Address: 3 V-7V m4,1 �A ey lid City: S'0c_ff—'Wn Zip: Facility Contact Person: 6 116 4r+ Contact Phone No.:( 7,0/`' ) D IV Make/Model of Monitoring System: V YZ- T LS 3 Std Date of Testing/Servicing: Z / / ZOD 7 B. Inventory of Equipment Tested/Certified Check theapproeriate boxes to indicate s ecific a ui ment ins ected/serviced: Tank ID: J 7 Tank ID: �d In-Tank Gauging Probe. Model: A$#6 / /In-Tank Gauging Probe. Model: I Ef Annular Space or Vault Sensor. Model: V-70 �KAnmdar Space or Vault Sensor. Model: .f Ik 1r_ 6 Piping Sump/Trench Sensor(s). Model:_ 2v4 WPiping Sump/Trench Sensor(s). Model: ZO Ef Fill Sump Sensor(s). Model: Zo k W Fill Sump Sensor(s). Model: ZO ❑ Mechanical Line Leak Detector. Model: '° ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: C 10 WElectronic Line Leak Detector. Model: LCt� ,el Tank Overfill/High-Level Sensor. Model: S jd'Tank Overfill/High-Level Sensor. Model: 5d. ❑ Other(sEecify equipment type and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: LJ Annular Space or Vault Se or. Model: El Piping Sump/Trench Sensor(s�, Mod ❑ Piping Sump/Trench Sen so ). odel: LJ Fill Sump Sensor(s). el: El Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. odel: ❑ Mechanical Line Leak ector. Model: ❑ Elechonic Line Leak Detecto . del: ❑ Electronic Line Lea- etector. Model: ❑ Tank Overfill/High-Level ensor. Mo ❑ Tank Overfill/Higl-Level Sensor. odel: ❑ Other(s ecif e ui ment type and model in Section E on Pa e 2). ❑ Other(s eci equipment t e and model in Section E on Pae 2). Dispenser ID: /- 7— Dispenser ID: 7-y ❑ Dispenser Containment Sensor(s). Model 201f ❑ Dispenser Containment Sensor(s). Model: 2�� ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis ensor Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: S- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 20` ❑ Dispenser Containment Sensor(s). Model: 7iU ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: F-10 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Z/JY ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). I f 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 apple'): ASVS Alarm history report Technician Name(print):ZAIJ 1~0 Signature: Certification No.: // a3 License.No.: O i7- g ;7d Testing Company Name: A ri—,as Phone NojOBJ Site Address: 311 K /-1AA/74/CV kD Date of Testing/Servicing: Page 1 fW3 03101 Monitoring System Certification D. Results of Testing/Servicing