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NI NG SYSTEMCE TIF' Q� Q c4 Ise By .=111 Jzrri,sdiciions fl"ithin the State of Colt is Authority Cited: Chapter- 6.7, Health and Sgfety Code; Chapter 16, Division 3, Title 23, California Code of'Regulations N ` 20 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be 09 prepared for each monitoring system control panel by the technician who performs the work. A copy otj1WVFR@NMlTeWA1K to the tank system owner/operator. The owner/operator,ptist submit a copy of this form to the local agen�e�l�f' stems within 30 clays of test date. ®, / Wim, a e�w A. General Information y , Facility Name: L'k ` /I Bldg. No.: Site Address:�U- a t1,, City:_..Zi , ^y 0 p: Facility Contact Person: Contact Phone No.: ( Ft L) t- Make/Model of Monitoring System: via- -- Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a in men t inspected/service. Ta k ID: Space or Vault Sensor. Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model:G�_ Piping Sump / Trench Sensor(s). Model: Z, ❑ Fill Sump Sensor(s). Model: ❑ Meclianical Line Leak Detector. Model. I J4 Electronic Line Leak Detector. Model _ t. ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: 1n -Tank Gauging Probe. P r Model: j Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: ,.. ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Electronic Line Leak Detector. Model: Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pa a 2). penser ID: D' penser ID: ,[Di Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: .I Z Dispenser Containment Sensor(s). Model: 'Shear Valve(s). Tank ID: LTE�- In-Tank Gauging Probe. Model: } Space or Vault Sensor. _� Model: 4 617 ,nnular iping Sump / Trench Sensor(s). Model: j� Z ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. - Model: ❑ Tank- Overfill / High -Level Sensor. Model: ❑ Other (specify equipment ty e and model in Section E on Na e 2). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specifZ equipment ty a and model in Section E on Pa e 2). ' D' penser ID: Dispenser Containment Sensor(s). Model:Z- L Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). D• penser ID: % �j– El Dispenser Containment Sensor(s). Ef Shear Valves) Model: r Z_ ❑ Dispenser Containment Float(s) and Chain(s)777tDispenser Dis enser Containment Float(s) and Chain(s). —,:]— Dispenser ID: ID: ❑ Dispenser Contaimnent 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). *If the facility contains more tanks or dispenses, copy this foam. Include informat' f'or ev tank and dispense 1t the fa ility. C. Certification - I certify that the equipment identii ed tleis document'Pwas ins ected/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 equi Sent. For any equips t capable of generating such reports, 1 have also attached a copy of the report; (check all that apptl): Sys` en et -up Alarm history report Technician Name (print): Ayj ��Ln kA,,- Sign ne: Certification No.: g'�j�� Li52 '73-t!T cense. No.: 11TG , t n'fi' I 3� Testing Company Name: C2 r CSA -y- Phone No.:(5> '7 , 6 // 2 Site Address: �+ ,� ,5 Date of Testing/Servicing:, %j / Pane 1 ol'3 14'10nU401-171g System CertificatioII D. Resaghr, o 03101 a