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MONS )RING SYSTEM CERTIFI .TIO c �� For Use B)),4 ll Jurisdictions if ithin the,Slate of California - Aulhorily Cited.• Chapter 6.7, Health and Seffely Code; Chapter 16, Division 3, Title 23, California Code of'Regulalions � 029 2007 This form must be used to document testing and servicing of monitoring equipment. A separate certificati0on or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this. must n) q the tank system owner/operator. The owner/operator must submit a copy of this form to the local a en it'�i��. � � � �� within 30 days of test date. g ;1r�$ A. General Information Facility Name: _ WAII755rh ,¢S Bldg.No.: Site Address: &/5/b City: Zip: 9��6 Facility Contact Person: 9119. �� Contact Phone No.:(�°f) Make/Model of Monitoring System: �/ Date of Testing/Servicing: 5'/ /07- B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates eciric equipment ins ected/serviced: rL] E[ectronic ID: OCA Tank ID: -Tank Gauging Probe. Model: 6t Y ❑ In-Tank Gauging Probe. Model: pular Space or Vault Sensor. Model: w ❑ Annular Space or Vault Sensor. Model: ping Sump/Trench Sensor(s). Model: 'lV 13 ❑ Piping Sump/Trench Sensor(s). Model: l Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: echanical Line Leak Detector. Model: IS P�A*L 6 ❑ Mechanical Line Leak Detector. Model: Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: nk Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: her(specify equipment t e and model in Section E on Page 2). ❑ Other(specify equipment t e and model in,ection E on Pa a 2). Ta ID: .0c.7 Tank ID: In ,e -Tank Gauging Probe. Model: M dt Z LJ In-Tank Gauging Probe. Model: ( nular Space or Vault Sensor. Model: yrs ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ZOO ❑ Piping Sump/Trench Sensor(s). Model: ❑ ill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:"ZbZeoo ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify equipment type and model in Section E on Pace 2). 11 0015, (s ecify ec ui orient lv e and model in clirnr E on Pa e 2). Dis enscr ID: / / Z Dispenser ID: 'l g �rspenser Containment Sensor(s). Model: Z-og FrDispenser Containment Sensor(s). Model: .!J Shear Valve(s). shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dis enscr ID: J?'r y Dispenser ID: Dispenser Containment Serisor(s). Model: ?yf3 ❑ Dispenser Containment Sensor(s). Model: .0'Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: TZ4 Dispenser ID: ,I"Dispemer Containment Sensor(s). Model: Zai ❑ Dispenser Containment Sensor(s). Model: .B'Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s)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 e i ent. For any equip lent capable of generating such reports,l have also attacw a copy of�th report;(check all that appl;'): ys - Alarm history report Technician Name(print): MA40 Signator Certification No.: x/83 License.No.: Testing Company Name:Aq,a,4 —7<S7 Phone No.:fl .-?C2 ) 7 - Site Address:Address: U �yiQ-12 �L 1�✓d-t� Date of Testing/Servicing: S /7- /-01% .. Monitoring System Certification .-* Page 1 of 3 03101 D. Results of Testing/Servicing