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4PE T Dispatch cS MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State o�f'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 se irate certification or re ort must be nre ared for each nonitorinLy system control panel by the technician who performs the work. A copy of this forest must be provide to the tank system owner operator. e owner/operator must submit a copy of this form to the local agency regulating TJST systems within 30 days of test date. k.' General Information acility Name: CO '2133 Bldg.No.: lite Address: ? r City Uc' 1 "t' dip: �; 7 ;acility Contact Person:_ `/L Contact Phone No.: ( 14-7-25-- vlake/Model of Monitoring System:�0�V? Tt z S"O Serial Number f ZS j t 5-C 91 tt p Q 2- )ate of Testing/Servicing: / / 06 B. Inventory of Equipment'Tested/Certified 0:1 /,y -i'e s�� 3 Z,3 so m t 5 heck thea ro riate boxes to indicates e¢ific mai2ment ins eeted/serviced: rank ID: 'TI u r Tank ID: In-Tank Gauging Probe. Model: (` ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 3"Piping Sump/Trench Sensor(s). Model: ']2 y 3 g p - 6 � KI-Piping Sump/Trench Sensor(s). Model: 7 q y 3 a S B'Fill Sump Sensor(s). Model: q y ®- Z R-Fill Sump Sensor(s). Model: ?g y3 A�--,3 z � Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 3 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: R Other(s2E! equipment type and model in Section E oneP � 2}. ❑ Other(s eci equipment a and model in Section E on Page 2). rank ID:'l-3 GolddTank ID: D In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Z) Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: B"Piping Sump/Trench Sensor(s). Model: '?`j 00,3Z3 12-Piping Sump/Trench Sensor(s). Model: ZrFill Sump Sensor(s). Model: 79H3 O —A 2 3 [!'Fill Sump Sensor(s). Model: :1 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ZI Electronic Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: :1 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: 2.Other( ecify a ui ment jMe and model in Section E on P e 2). ❑ Other(s ecify 22u, ment a and model in Section E on P e 2). Dispenser ID: y 2 Dispenser ID: 5 '{ ZI Dispenser Containment Sensor(s). Model:_.? 9 y3 Aa- Z3 ❑ Dispenser Containment Sensor(s). Model: 7 95',3 &o-S t 3 Shear Valve(s). ❑ Shear Valve(s). ZI Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: S Despenser ID: � � 7 Dispenser Containment Sensor(s). Model: 7 7 8D -3 z Dispenser Containment Sensor(s). Model: _751/3-90-32-3 Shear Valve(s). ❑ Shear Valve(s). - p Dis enser Containment Float(s)and Chains. ❑ Di enser Containment Flo! s)and Chains . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ZI Shear Valve(s). ❑ Shear Valve(s). DDispenser Containment Floats and Chain(s). ❑ Di enser Containment Floats)and Chains . '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 equipment. For any equipment capable of generating such reports,I have also attached a copy of the report,(check all that apply): 3-System set-up C-Alarm history report Technician Name(print): /ps f f� Signature: - :ertification No.: A 3("j[7 License.No.: 302015 Cesting Company Name: CHARLES E. THOMAS COMPANY Phone No.: (310 ) 323 6730 address: 13701 So. Alma, Gardena, GaladOrnia 90249 Date of Testing/Servicing: G //q /06 Page 1 of 3