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H t 41, ' MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California .4uthorin•Cited: Chapter 6.7. Health and Safen•Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. Th: owner'overater must submit a con•; of this fnrTn rn the lnral aoencv reo,ll�qri„cy t_tc_T �rAt Nyithin 30 dans of test date. A. General Information Facility Name: 5 7 5;5-P2v IC4F7 _ Bldg. No.: Site Address: -36-C)5- qtr 4U V D/z_ Cite: 51b_,- -7WJ . Cry, Zip: qb 2Z3 Facility Contact Person: Contact Phone No.: I ivlake,Model of Monitoring System: 6�4yk_ AST' g —p Z Date of Testing/Servicins: `[` /-Z-7 /o-a_ B. Inventory of Equipment Tested/Certified Check the ap2ropriate bores to indicates ecific equipment ins ected/sen•iced: Tank ID: I — 17.�5��L Tank ID: (I ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: QYAnnular Space or Vault Sensor. Abdel: (_,¢L5—1 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensori.$). Model: ❑ Piping Sump"Trench Sensor(s I. Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: I ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecif equipment type and model in Section E on Pa_e 2). ❑ Other(specify e ui ment type a-d model in Section E on Page 2). Tank ID: 2- - k)A P,—A 4,— K au[ Tank ID. EJ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: &'Annular Space or Vault Sensor. Model: C-,4101Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensork-0. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Abdel: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Senses. Model: ! ❑ Other(specify equipment nre and model in Section E on Pale 2). ❑ Other(scecifv equipment tv e and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Abdel: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Vaive(s). f ❑ Dispenser Containment Floau sl and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ! Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensori,$). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ^ : i,��-C�'r_:. u;!,.,1nnlcCii:ivail,, Ci.�un�;. ContainmentContainmenti Fvaii�r a,-Id r, u�.u3�n1�1. ❑ �"C Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Fl=(s)a-d Chain(s). '!f the facility contains more tanks or dispensers,copy this form. include information for eery 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 11 that appljq: ❑ SN sleEn set-u Al ory report Technician Name(print): 4LU IN L, A4 14/g Signature: ( ��`, Certification No.: License. No.: $04('K?O Testing Company Nam ee vN e_Q�c,S/4 tJ JAWK /►fir Phone No.: Site Address: '��5 /(/,4U �4 ZJaG/LTi,�J Date of Tes::ng Servicing: fiel/_�a e Pace I of 3 03/01 Monitoring System Certification D. Results of Testing/Servicing