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<br />MONITORPiG SYSTUM CERTIFICATION
<br />For Use 3y.411 Junsaictions Within the State of California
<br />Auxhoe!,'Clsed-- Ciaprer, 6.7, Haaiih aad Safety. Code; Chapter. 16, Division 3, 7-71le .13, California Cxiew
<br />f ,Zg,,Jat"s
<br />This forin must be used to document testing and servicing of monitoring equipment- Ajenarate certification Or MCA MWE be nwDared
<br />for each monitoring system contras panel by the technician who pedomis the VoeL A copy of this form must iv provided to the tank
<br />system owner/operator. The owner/operator imwt submit a envy of this form to the local agency reTulating UST systems wahin 30
<br />days of test date_
<br />A. Generil Informadon
<br />Facility Name: S�AKJ3144cA 21 <-,t t' Bldg., No.,
<br />Facility canucr Persow. -:70— _. Coma Phone ,90.:
<br />M,ake/MYY" f of 2N(onit� Sysu= Date of Testing/Servicing: -j"FL11"
<br />If the bleffity conmins mote tanks or dispensm, copy This totes. Inclilde infimnamm for every tank and dispenser at the fatality.
<br />C. Cardfim6m - i aowy a" ae tqu*_,i&uwed in this docaluent w-�w iagpttir _ _..-ia amordaft *ith the
<br />guidelines. Attached to this Calfication is information (*,g. manubeturen'necewry to vel-iry that dlis information is
<br />coxTect nW a Plot Plan showing the layout of moni'lar,mg eqqjWulent- li%r ally eq aillable of genwaling such repatis, I have also
<br />attached a copy of the IXZMIV J.- System set-up AUUM bisk" C29
<br />i� 0z
<br />Technician Name (print)- e ^ f Sign2uxre:,
<br />Certification License. No.:
<br />Te:-�ungCompany '4ame:..CtiAKi,,Oeu
<br />Address: PC-,--6r-x 15g�5, SACk/we"Ib 'e-4, Dateoff,,ring(Servicing:
<br />Page 1 of 3 1001
<br />-vionitonng System Certification
<br />TrE
<br />.Tak ging probe.
<br />n
<br />Modek
<br />R. Ganging Prcbc. Mid ch
<br />War Spacc or Vault Sensor.
<br />Modet. 3,10 45T
<br />M= ar Spacc or Vault Sensor. Model: 7j)
<br />Piping sump / Trench w. i°
<br />Model: Jj -0
<br />j V$*ng saw / Tiencit sens*s). Model: 0,751070
<br />U'All Sump seusor(s�.
<br />a Mccilanical Une Leak Dc==
<br />Motick -Z-t V-
<br />Sensoos). U=W..
<br />allAccilanwal Lao Leak Detector Model. 3 rP
<br />Q Electronic Line Leak Detector.
<br />Modek
<br />[3 Elecramic Lim- lx& Derector. Model: ff
<br />o rank ovc&u i Mgh-L-evel Sensor.
<br />Modek
<br />0 T=k Overffit i High-1,evel Sensor. Wmdel:
<br />and model in Socrion E on P2
<br />(specify !Tn��SP
<br />Tank M.-
<br />Tank JW.
<br />Q fn-o-iank Gauging Probe.
<br />Modet
<br />Q En-TankGiniging.Probe- Modch
<br />j Q Auuniw Space or Vanit Sensor.
<br />Modeft
<br />3 -Annular Space or Vault Sensor. Mcdch
<br />Q Piping Sump / Tzench Sensor(s).
<br />Model:
<br />Q Piping an. r. I Tmch Sensor(s). Modek
<br />Q Till Siminp Sensor(s).
<br />Model:
<br />Q Fill Sump Sensor(s). Model:
<br />:3 Mechanical Line Leak Deu=or.
<br />Model:
<br />Q Mechanical Line Lzak Detector. Modet
<br />:3 Electrom Loa L--ak Dezector
<br />Mo&l.,
<br />;i :3 Electmaic Lim Leak Derecror. Moact
<br />3 Tank Overfill ffigh-Level Sensor.
<br />Modeh
<br />M -rank Overffl / ffigh4zri Sensor. Me&]:
<br />Q Other (somi and niodel in Secdon E on Pa�z).
<br />lent
<br />t--- -ent tvpe and Model in Sectim E an 2).
<br />W-72
<br />NOMA
<br />I it W
<br />offt— f wit,
<br />'tip, ;;i ti t
<br />If the bleffity conmins mote tanks or dispensm, copy This totes. Inclilde infimnamm for every tank and dispenser at the fatality.
<br />C. Cardfim6m - i aowy a" ae tqu*_,i&uwed in this docaluent w-�w iagpttir _ _..-ia amordaft *ith the
<br />guidelines. Attached to this Calfication is information (*,g. manubeturen'necewry to vel-iry that dlis information is
<br />coxTect nW a Plot Plan showing the layout of moni'lar,mg eqqjWulent- li%r ally eq aillable of genwaling such repatis, I have also
<br />attached a copy of the IXZMIV J.- System set-up AUUM bisk" C29
<br />i� 0z
<br />Technician Name (print)- e ^ f Sign2uxre:,
<br />Certification License. No.:
<br />Te:-�ungCompany '4ame:..CtiAKi,,Oeu
<br />Address: PC-,--6r-x 15g�5, SACk/we"Ib 'e-4, Dateoff,,ring(Servicing:
<br />Page 1 of 3 1001
<br />-vionitonng System Certification
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