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s MO*ORING* SYSTEM CERTIOATION For Use By All Jurisdictions Within the State of California Authority Cited; Chapter 6.7, Health and Safety Code;Chapter 16,Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or re on must be prenared for each monitoring system control panel by the technician who performs the work. A copy of this form muwtl system owner/operator. The owner/operator must submit a copy of this form to the local agency regulaun days of test date.. ( L P 2 A 2 Facility Name: rv'/ 1,-' �`�C/$ � Cori Site Address: City: x t No ia�,I zy> 11 $ C R Facility Contact Person: P.,4 R p v'1( CAntact Phone No.:( a c9 ) 6 13 e—c: 6 b Make/Model of Monitoring System: (?,,Ld TJZ Co &1k C Date of TestingiServicing: `j I Il / D2 Liventt ry of Equipment Tested/Certified Check the appropiiate boxes to Indicates f1c ui ment Ins ed/sereIced: Tank ID: / E64L 13rC Tank ID: '3 iP/lE Is 6L_ 2'1n_=Tank Gauging Probe. Model: ,/t14G 2 O"Tn,Tank Gauging Probe. Model: 0-7Qnular Space or Vault Sensor. Model:-P,46.;Z5"?®14$eeO Er?iunular Space or Vault Sensor. Nfodel: Fi40:Z570[a aaa C, L3"lSiping Sump/Trench Sensor(s). Model: f jO-�2_ 9 aocc®i o ®'Piping Sump/Trench Sensor(s). Model: t�$b 59%tyC�Olp ❑ Fill Sump Sensor(s). Yodel: ❑ Fill Sump Sensor(s). %fodel: 1 GalMechanical Line Leak Detector. Model: 9"(,fechanical Line Leak Detector. Model: L 4,.,> z _ ❑ Electronic Lire Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s eci a ui men[t and model in Section E on Paee 2). ❑ Other(specify equipment t and mode}in Section E on Page 2). Tank ID: -P Zd 1w 14i 6'1 Tank ID: ❑In-Tank Gauging Probe. Model: ll((,4C—Z ❑ In-Tank Gauging Probe. \Iodel: alnnular Space or Vault Sensor. Model: P+0 a.Selal 010C ❑ Annular Space or Vault Sensor. Model: ®'Piping Sump/Trench Sensor(s). Yodel:f'41 OX57`1AOt-0010 ❑ Piping Sump/Trench Sensor(s). Niodel: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). \lodel: 21dechanical Line Leak Detector. Model: e—t?— ci a ❑ 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. \fodel: ❑ Other(s ecify equipment and model in Section E on Page 2). ❑ Other(s eci a ui ment tME and model in Section E on Page 2). Dispens$r ID: I—Z Dispenser ID: • -7-3 " ❑ D�is.ppeenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: � EY Shear Valve(s). U-S'F ear Valve(s). U-15is enser Containment Float(s)and Chain(s). ❑"Lb`s nser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: O 7ghear Valve(s). ❑ Shear Valve(s). C_Dis nser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID:, 6 —4- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Er-Shear Valve(s). 11 Shear Valve(s) 1 4fithspenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s) I� *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser a: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 equent. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): Q'System set-up U history report_ Technician Name(print): /9L<.I N4_.. C( 1L/3 �tJ Signature: ..,.�G_ Certification No.: License.No.: �cY �t 0 Testing Company Name: �f1,�1�tf�oN Jail lSla� fly K P4-S7/A-(;-Phone No.:( c%C)��( � Site Address: fbal �. YoS4-1A1745_ AVS rl(r1/. l�C61 � DateofTestinlSernicinQ: Page I of 3 03/01 INIonitoring System Certification