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' �� u -� E T Dispatch -2— MONITORING Z.1VI®lo I TORI G S'VS'I EM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16 Division 3, Title 23, California Code of Regulations Chis form must be used to document testing and servicing of monitoring equipment. A separate certification or renort must be orenared for each nonitorine system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. Che owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. k. General Information ;acility Name: ,yA Bldg.No.: Site Address: P'c f Ci City: Zip: Ok`'��j l ?acility Contact Person:_ Contact Phone No.: 0036 vlake/Model of Monitoring System: --L y, -'s c, Serial Number 9cn _S 1 i^s 2 C SG date of Testing/Servicing: z5�z� c�.t B. Inventory of EquipmentEquipment'Tested/certified y c"3 � heck thea ro riate boxes to indicates ecific equipment ins ected/serviced: Cank ID: j] 61 v &-- Tank ID: —1 3 In-Tank Gauging Probe- Model:— C3 In-Tank Gauging Probe. Model: 7 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑'Piping Sump/Trench Sensor(s). Model: 7 Y ""C .3`L 3 (] Piping Sump/Trench Sensor(s). Model: 7`I -5 P G - 3-Fill Sump Sensor(s). Model: z> 1D-'ill Sump SensOr(S). Model: 7`l y,3 G'G S Z. 3 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 3 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 3 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: 3 Other(snecify equi mens=e andmodel in Section E on P ae 2). ❑ Other(specify equipment type and model in Section E on Page 2). Cank ID: J ?7 -cl Tank ID: 3 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 3 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 3-Piping Sump/Trench Sensor(s). Model: `7 9 O -- _S 2 S ❑ Piping Sump/Trench Sensor(s). Model: ❑"Fill Sump Sensor(s). Model: 7 S {3 e(:1 - ❑ Fill Sump Sensor(s). Model: 3 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 3 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 3 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: 3 Other( ecify equipment ty e and model in Section E on Pae 2). ❑ Other(s ecify equipment type and model in Section E on Page 2). )ispenser ID: /I Dispenser ID: 3 3 Dispenser Containment Sensor(s). Model: _7 <{ P 0 -3 } ❑ Dispenser Containment Sensor(s). Model: 7`%V.3e,0 _ Z 3 3 Shear Valve(s). ❑ Shear Valve(s). 3 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). )ispenser ID: �/ Dispenser ID: 1 5' ] Dispenser Containment Sensor(s). Model: 7 71/ ❑ Dispenser Containment Sensor(s). Model: 3 Shear Valve(s). ❑ Shear Valve(s). 3 Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Floats)and Chain(s). )ispenser ID: Dispenser ID: 3 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 3 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 ever),tank and dispenser at the facility. 1 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): L-2-System set-tap Ca-Alarm History report 'echnician Name(print): dt S r Signature: rz — ,ertification No.: - License.No.: 302015 'esting Company Name: CHARLES E. THOMAS COMPANY Phone No.: ( 310 323 6730 .ddress: 13701 So. -alma, Gardena, Cafi of nia 90249 Date of Testing/Servicing: i/ C Page l of 3