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P'. MONWRING SYSTEM CERTHFJAAT.B�EGE WED /.Or C'sc BI"1/l Jnris&lions 117111in the Scale q ('rrlifiu•rria Awhoril_v Cited Chapter'6.7 Ileullh C'orle, Chtr/rter/6, Division 3, Tille 23, Culifnrnicr C(W'43/2008' This form Must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who p rms-the work. A copy of t1hiQ9691yiI`6P W(I to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency V stems within 30 clays of test&late. A E A. General Information Facility Name: OLEtj6l/� eWr LW.0,51D17A' -L__ Bldg.No.: Site Address: `J00 W. 4®SPI-rA-(_ City: Zip: Facility Contact Person: CIPC AAk Contact Phone No.: ( ) Make/Model of Monitoring System: 41,0 Date of Testing* /Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecitic equipment ins ected/seryiced: Tank ID:_,gh Tank ID: Al to-Tank Gauging Probe. Model: _ ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model:_t>UOtL FtAAT lS ❑ Annular Space or Vault Sensor. Model: A Piping Sump/Trench Sensor(s). Model: (AL-6 ❑ Piping Sump/Trench Sensor(s). Model: Q9-Fill Sump Sensor(s). Model: mus ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leal:Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leal.Detector. Model: ❑ Electronic Line Leak Detector. Model- C3 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equi orient type and model in Section E on Page 2). ❑ Other(specify equipment ty e and model i Section E on Pa 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑7n-Tank Gauging Probe. del: ❑ Annular Space or Vault Sensor. Model: ❑ Arundar Space or Vault Sensor. del: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Mo ❑ 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/High-Level Sensor. Model: ❑ Other(specify e ui ment type and model in Section E on Page 2). ❑ Other(s eci equipment ty a and model in Sect' n E on Pa e Dispenser ID: Dispenser ID,- C3 D;❑ Dispenser Containment Sensor(s). Model: A ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). El Shear Valve(s). L3Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ 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). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facilit . 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 equi ment. For any equipment capable of generating such reports,I have also attached a copy of/r the report;(check all that applp): System t u larm history report Technician Name(print): X400 1,p��V .b.,o Signature: L� 5Z � Certification No.: / License.No.: :3&Z 0'� Q lf�' Testing Company Name: ° s Phone No•:(k6_!?__)-'j"'`f'`/ — 002 Site Address: ,'$-1>0OSt�t-rC_ Date of Testing/Servicing: /Z_Z /0a Page I of 3 03/01 Monitoring System Certification D. results of Testing/Servicing