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MONIr G SYSTEMC TIF TI ?se By A//Jurisdietions 11'ithin the State of'Ccrhfor ... Arrtlroi•ity 01eck Clrcrpter 6.7, Health arid Safety Code; Chapter 16, Division 3, Title 23, California Cod% ' This form must be used to document testing and servicing of monitoring equipment. A separate certificatioi of I ort: 11aList-be prepared for each monitoring system control panel by the technician who performs the work. A copy of th °fdPm r'ii tst b rpt c d 0 the tank system owner/operator. The owner•/operator must submit a copy of this form to�,bA local agencyIr1i��trrt}S ems within 30 clays of test date. A. General Information Facility Name: X, e T'e- el" tri/ C1,.e �✓ C5j Bldg. No.: Site Address: _- E_r, D� L, / - CT7•-LC3 A..cgn) city:_. Zip: Facility Contact Person: - U Contact Phone No.: ( ) �.� 3 Make/Model of Monitoring System: Vz� - D LS'O-' ?=p a ,— 7_ L S .? ate of Testing/Ser•vici g: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/service 7nular ID: 5AS /Tank Gauging Probe. Model•_Space or Vault Sensor. - Model: Zc3 El Piping Sump / Trench Sensor(s). Model:yB A -Fill Sump Sensor(s). Model: 2� ❑ Mechanical Line Leak Detector. Model: WElectronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ® Other (specify equipment type and model in Section E on Page 2). Tank ID: :::�L - 4-y) c5 S 7 - In -Tank Gauging Probe. Model: .A_ ice, / J Annular Space or Vault Sensor. Model: !� Piping Sump / Trench Sensor(s). Model: 7 n <3 A Fill Sump Sensor(s). Model: $ ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: - r- ❑ Tank Overfill/ High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Paee 21 DispenserID: / .,X�Dispenser Contain nt Sensor(s). Model: s+ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(< Dispenser ID: gig' 4- Y UnDispenser Containment Sensor(s). Model: 4WF' ear Valve(s). ❑ C'Wenser Containment Float(s) and Chain(s). 5��_t nt Sensor(s). Model: 45r-Shdar Valve(s). ❑Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this Tank ID: / Olin -Tank Gauging Probe. Model:�� (Annular Space or Vault Sensor. Model. Piping Sump / Trench Sensor(s). Model: d�! ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: A Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specifye in ment ty e and model in Section E on Page 2). Tank ID: l C -S In -Tank Gauging Probe. Model: t�Annular Space or Vault Sensor. Model: i'd-Piping Sump / Trench Sensor(s). Model: 5 -Fill Sump Sensor(s). Model: LJMechanical Line Leak Detector. Model: 4W Electronic Line Leak Detector. Model: L ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecif e ui ment type and model in Section E on Page 2). Dispenser ID: "? •� E>Dispenser Containment Sensor(s). Model: AeF=Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: _ �/ / /6 0 Dispenser Containment Sensor(s). Model: 202 WShear Valve(s). ❑ Dispenser Containment Ploat(s) and Chain(s). Dispenser ID:- � 7t /T ZrDispenser Containment Sensor(s). Model: 22 AkShear Valve(s). ❑ Dispenser Containment Float(s) and Chnin(sl 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. r any equi capable of eneratin pr gc g such reports, I have also attached a copy of the report; (check a!/that npp/p): ys In se -u Alarm histo�repor�tTechnician Name (print): � Ay;' 2_0 F -r - SignatureCertification No.: -� 'i3 L! 3K 7 j License. No.: Testing Company Name: ! MT O r r> a f � ; r Phone No j tog Site Address: Date of Testing/Servicing: 7.? p� Monitoring System certificationPare I of 03/01 D. Renu is (if Testup /ServieeEt ;