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T _ MW _�TO�� NG SYSTEM CERTI C'ATI®�� Wc { or Use By,411 Jru•isdictions If'ithin the State gf California �� 1J Authority Cited. Clutpter 6.7, Health and Safety Code;Clutpter 16, Division 3, Title 23, California Code of'Regarlatlons JUNThis form must be used to document testing and servicing of monitoring equipment. A separate certificatiion�or�r��rt8must be prepared for each monitoring system control panel by the technician who performs the work. A co 0 the tank system owner/operator. _The owner/operator must submit a copy of this form to the to al a �H d to within 30 days of test date. —el g � r � y ems A. General Informa Facility Name: tio e— Bldg.No.: Site Address: 35�� )/-�(/y Ci O r� City: J G�n Zip: Facility Contact Person: tJA/u Contact Phone No.:( zo Make/Model of Monitoring System� ^ /DU Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified ('beck the appropriate boxes to indicate specific equipment ins ected/serviced: Tanlc ID: I b5 G Tanlc ID: ❑ In-Tank Gauging Probe. Model:_ _ ❑ In-Tank Ganging Probe. 1p ® Annular Space or Vault Sensor. Model: = ModeL- Piping Sump/Trench Sensor(s). Model: ❑ Annular Space or Vault Sensor. Model: ❑ Fill Sump Sensor(s). Model: G�— ❑ Piping Sump/Trench Sensor(s).. Mo ❑ Mechanical Line Leak Detector. Model: ❑ Fill Sump Sensor(s), del: ❑ Electronic Line Leak Detector. Model: ❑ Mechanical•Line Leak Detector. del: ® Tank Overfill/High-Level Sensor. Model: E3 Electronic Line Leak Detector. Mo ❑ r. Model: Other(specify equipment type and model in Section E on Page ❑ Other(specify erfill/eq i2i ent type d model in Section E on Pa a 2). Tank ID: Tank ID: L3 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Senso. Mo ❑ Annular Space or Vault Sensor. del: ❑ Piping Sump/Trench Sensor(s). del: ❑ Piping Sump/Trench Sens s). Model: ❑ Fill Sump Sensor(s). del: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Mo l: ❑ Mechanical Line Leak Detec r. Model: ❑ Electronic Line Leak Detector. Mode ❑ Electronic Line Leak Dete or. odel: ❑ Tank Overfill/High-Level Sen r. Model: ❑ Tank Overfill/High-Lev I Sensor. M del: ❑ Other(s ecif equi ment type and model in Section E on Page 2). ❑ Other(specifya ui Dispenser ID: meat tv a and model in Section E on Page 2). Dispenser I D: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Senso ❑ Shear Valve(s). r( )• Model: El Shear ❑ Dis censer Containment Float(s)� id Chaii s). ser C s). El Dispenser Containment Float(s)ai Chi'i(s). Dispenser 11u): ❑ Dispenser Containment Sensor(s). o el: Dispenser ID: ❑ ❑ Shear Valve(s). Dispenser Containment Sensor(s). oriel: LI Dispenser Containment Floats)and C in(s). 13 Shear Valve(s). 13Dis Dispenser Containment Floats) d Ch ' (s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). oriel. ❑ DispensCainment Senso s). Model C3 Shear Valve(s). ❑ Shear serValC s). ❑Dix enser Containment Float(s)and Dispenser hain(s). ❑ Dispenser Containment Float(s)and Chain(s). If the facility contains more tanks or ispensers,copy this 101-111. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/seryiced 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 n//that app4v): ,WSystem set-up 'Alarm history report Technician Name(print): AI/i i7 fP/��Y Signature:_�_ f Certification No.: rc'_C z F52 �� F4 /I�^Z, License.No.: � n$-/ 3� Testing Company Name: /► „r r>A 5 r- Phone No.:( 2-2) �, $ite Address: -?Sor AJAU/1-1 l' e rA Date of Testing/Servicing: 6 /lrr/ F- Nlonitoring System CertificaPagc I of 3 tion W` 03/01 1�. :Resnults of Testsnr;/Servicing