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MoNrrORING SYSTEM CERTMCATION <br />For Use By All Jurisdictions Within the State of California <br />;4 whority Cited- Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code ofRegulations <br />Ibis form must be-- used to document testing and servicig of monitoring equipment. If more thaa one. <br />w <br />-c-&-#,arate_cerdfication'6ry"j _rtifigAbemre•atedfig.7. <br />;�izt <br />each moditoring system control panel by the technician'who perform' the wo& A COPY of this form must be <br />provided to the tank system.owner/operator. The ownedpperator must submit a copy of this form to the locaj <br />age,ncy r�gulatuag USTIi: svvithin 30 days of test date. Instructions are printed on the back of this page. <br />Facility Nmc:'-- 1 r -j -) c- q Bldg. No- <br />Sit�Address: 3 7 City, Tr If) r � Zip: 3S_7 <br />Facility Contact Person: Contact Phone Noy <br />�' . 5 J 7 <br />Make[Model of Monitoring SystSystem:j /--'5. —3 5 oD C . i-,,GTDate of Testingl-Set-vicing <br />B."Inveiltoryof*EqnipmentTested/Cerfified <br />Check the appropriate boxes to indicate specificequipmentins <br />T <br />TankID. <br />Model: ill A <br />6I <br />PVrzoubl_t- <br />JAnnularGSpace <br />CS=paWenA <br />PVraoubl,t <br />orSensor. Modcq7) I/ : .L <br />MMoodd&&.- 14ff15) <br />Sensor. <br />'M-AIrnTiu=lakr or <br />SUMP / Trench SMSM4 M94cl:; <br />)RI Pi12) V. <br />"U'Piping Sump ITtimch Scas� _Model- <br />E3 -Fill Sump Scas'DE4 - - Model: <br />Q'Fill-Sump Smsoz(s). Model:'M <br />Mocha . nical Line Leak Detecor. ...Model <br />Li=Lc*Pct:ctor;. -.Modc1;-2.SjJ2 �Ry <br />El EloctroniclincLeak Detect". Model. <br />C1 Mqctrcknic Unc Leak Detector. -Modek <br />'0 Tank Ovcrf ill I FFtgh­Lcvc1 Sensor. Mod& A,1+ -T4 <br />"G Tank Overfill I High4--vel Sensor.. Mod& <br />)1f-DL*spcnscrContainn=tSc=r(s).MQ&cL- 4,-�t <br />'W,Dispc.ascrqorrtainrncqtScnsor(s). Model: <br />0 ShcarValvc(s). <br />0 Shear valvc(s)- <br />13 DLVcn= Containment Floats) and ChaiiI4 <br />ODispenser Containment Floc s)and Chain(s).- <br />b Other (specify equrpmexrt type and model inSectioaEonPW2)_-':. <br />0 Other (specify cquipincat.tyr- and model in Section -E.00 Page 2).-- <br />Tank ID: <br />Tank ID. L <br />In Tank Gauging Probe- Model: <br />'U <br />0 In -Tank Gauging Pmb-'. 7Modcl:- <br />'Annular q_0 <br />Annular Space or Vault Sensor. Modet <br />Space or Vault, Sensor. ..Model: <br />\0 Piping Sump /TratchSensor(s). Model:- <br />0 Piping Sump/Trench So= . Modet <br />r(s) <br />0 Fill Sump Smsor(s). Model: <br />0 Fill Sump Sensor(s). Modcl:- <br />')R- Mechanical Line Leak Dctc=. Model <br />0 Mochanical.I.Inc. Leak Detector.. Model: <br />0 Electronic line Leak - Detector. mod&- <br />0 Electronic I;= Leak Detector. . Model: <br />`0 Tank Overfill 1IEgh­Levd Sensor. Model: F rn,- o rp, o�A <br />•NEI <br />0 3ank,0vedill / Wigh4,cycl Sensor. Model: <br />'DLVcn= <br />DLVcnsw Containment Scnsor(s�' Model: �� <br />E3 Coatainrqcat pcnso[(S)- . Model: <br />S)_ <br />0 Shear valve(s). <br />0 DLVa= Containment Floats) and alain4 <br />Q DLVenser Containment Fjoat(s) and amin(s� - <br />0 Other (specify cquipmeattyke and model' in Section Bon Page 2): <br />0 Other (specify equipment type and model in Section E oa Pagm-, 2}. <br />C. Certification -I certify -that the equipment Identified in this document was inspected/strviced.in -accordance with the <br />manufacturers' guidelines. Attached to -this. Certification is information (e g. manufacturv& checklist) necessary to <br />verify that this information is correct and a.Site Plan showing the layout of monitoring eq meat. For any -equipment- <br />capabl'e of genemting such reports, I have also attached a copy of the (chezk- aff that applj9 emse(-up report; <br />"--0 Alarm history report. <br />Technician Name (print):t�ic_ No.: Siga� 6 �f-_-­ <br />Gcz <br />