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MON&RING SYSTEM CE TIF .ATI I For' Use ffv. 111,Jurisdictions Within the Slate gf Cahfor•nia -lrrthori(v Cited: Chcrl-ver 6.7, Health ancl.Scr]ety Cocle; Chapter 16, Division 3, Title 23, California Code of Ti �ilfrti�uzs �� ��,qq,,^�� This form must be used to document testing and servicing of .monitoring equipment. A se crate certific�f5,tT, Wy� rt mt�nit° prepared for each monitoring, system control panel by the technician who performs the work. A copy of this forw"qi ed to the tank system owner/ogerator. The owner/operator must submit a copy of this form to the local agency '� $° ,Is Q i within 30 days of test date. ✓ ^�, // A. General Infor ation FacilityName: I-vi i Site Address: % .1iN41 � fCity Facility Contact Person: Bldg. No.: 42 Zip: t Contact Phone No.: Make/Model of Monitoring System: r & X Date of Testing/Servicing: fb / / B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: P/ / Tank ID: ❑ In -Tank Gauging Probe. Model: 1) -!el ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: _> - ❑ AnnUlar Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: - ❑ Piping Sump / Trench Sensor(s). Model ❑ Fill Sump Sensor(s). Model- ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leal: Detector. Model: ❑ 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 cify equi meat type and model in Section E on Pa =e 2). ❑ Other (specify e ui ment type and model in Section E on Pa e 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill I High -Level Sensor. Model: ❑ Other (specify a ui ment type and model in Section E on Page 2). ❑ Other (s ecif equipment t e and model in Section E on Page 2). ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: IDispenser ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(-,) and Chain(s)• ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: LI Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ 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). Ij *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/service in accord. cc wit 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, l have also attach d a copy of the report; (check ah' that apply): ❑ Sys!$m se# -up ❑ Yarna histol report Technician Name (print). Signature: Certification No.:License. No.: �( 96 .-.11g3 eC`�S Testing Company Name: �� Tinr T) A t- Phone No j - l2q N __ �- r Site Address:) / ®c Date of Testing/Servicing: Page 1 of 3 Monitoring System Certification D. Results of Testing/Servicing 03/01