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11 <br />23-11MUM <br />RE ,D <br />MONITORING SYSTEM CERTIFICATION 1 9, � 01 Z <br />For Use By All Jurisdictions Within the State of California <br />Authority Cited: Chapter 6.7, Health and Safety Code: Chapter 16, Division 3, Title 23, California Code of Regulations <br />This form must be used to document lest,ing and servicing of monitoring equipment. A separate certificator, or reC_Wj§P <br />e -�n monitoring System control panel by the technician who Perform$ the work A copy or this form must be provided In the <br />ac <br />cmnertoperator. 2 <br />F <br />The twnerloperalcir muse submit a copy of this form, to the local agercy regulal�inq UST systems within _'�o <br />A Genc-ral Informabon <br />Fablily Maw <br />- <br />Site Aciclress <br />U N [TI ' .--D PACIPIC-if 5446 Bldg. No.: <br />1403 COUNTRY CLULi Stxv city Zip <br />1`301ilty Gonlad Person Ci3niaci Phone No.: <br />MakelmOdct Of Wnitoring SYStern Y.F'_UDER ROOTTI-S 3io Date afTestingiScmong: 5110117 RrzTEST FLOAT <br />B. Inventory of Equiprneilt TesteNCenified <br />Check the appropriate boxes to indicate specific equipment inspac ecitzerviced: <br />Tank to: 87 Tank Size, <br />Tank 10: 91 Tank Size, <br />[D In -Tang Gaging Probe, Model. MAO -1 <br />0 rn-Tank Gaijgrng PrdW, Modet N1 A(3-1 <br />M Annular Space or Vault Sensor Modet 302 <br />0 Anwar Space or Vault Senrw Madel 302 <br />12] Piping Sump 1 Trench Senser(s), Model: 209 <br />0 Rping Sum:) I Trench Sensor(s). Moe( 209 <br />Ej Fin Sump Senscr(s) model- <br />0 Fill Sump Senm(t). Wdel. <br />Mcchaniral Line Leak Defector, model LD20% <br />0 Mechanical Line Leak Detector Model, LD2000 <br />F3 F lewon� Line Leak Detector Model <br />0 Electronic Line Leak DetworModel' <br />Q Ta!lk Overfill,High-Level Sensor, Model FLAPPI-M <br />N Tank Overii; I I Hj5jh.Lcyaj &enstr, model: F1,1PPRA <br />0 Other (specify equipment type and model in Section C on Page 2). <br />El Other �specify equipment typo and model in $=ion E on Page 2) <br />Tank 10: DIE Tank Size: <br />Tank I D: Tank Size; <br />0 In -Tank Gauging Probe. model: MAU-1 <br />0 In -To nk Gauging Probe Model <br />0 AnnularSpate orVault Sensor Model: 303 <br />E3 Annular Space or Vault Sensor. Model - <br />ED Piping SVMP f Trench Sonsor(s). Model 208 <br />[1 Piping Sump I Trench Sensor(s) mwe[ <br />0 Fill Sump Sensof(s), Model, <br />E) Fill Sump Sonw(s), Model: <br />0 Mecnartical Line Leak Dwt , woc Model. LD2000 <br />0 Mechanical Line Leak Detector Model: <br />0 ElKljron4 Line Leak Detector Model <br />El Electronic Line Leak Detector. Nlodcq, <br />Tank Overfill ! High -Level Sensor, Model. FLAPPER <br />[j Tank Overfill f High -Level Sensor. Model: <br />Other (specify eqvipment ype and model in Section E on Page 2). <br />0 Oth-cropecify eqvipment type arid model in Section E on Page 2) <br />Dispenser ID: 1-2 <br />Dispenser ID: 3-1 <br />0 Dispenser Containment Sensor(s), Model: <br />0 Dispenser Containment Sensor(s). Modal <br />0 Shear Valveo), <br />0 Shear Valve(s), <br />0 Dispenser Containment Float(s) and Cha.,n(s) <br />C3 Dispenser Containment Float(S) and Chain (s), <br />Dispenser 10: <br />Dispenser 10; 7.8 <br />Cqintairmenl Sensorfs). Model, <br />Z Dispenser Containment Sensor(s) Model: <br />0 Shear Valve(s) <br />W Shear valyc(si- <br />El Dispenser Containment PloaUs) and Chairi(s) <br />0 INSMASer C43mainmem Flooitjs) and Chainis). <br />Dispenser ID: <br />Disms Lir ID: <br />0 Dispenser Containment <br />0 Disoenstr Containment Sensor(s) Model: <br />Sensor(s), Model: <br />0 shearvalve(s) <br />S hear Va lve(s). <br />11 D15,5enser Comamment Float(s) and Chain(s). <br />Dispenser Containment Floats) and Chain(s). <br />,ir the tacitftycvnjains more tanks or dispensers. copy this form IrZude infannation for every lank and dispenser of the facility. <br />C. Certification - I certify that the equipment Identified in IthIS 00cumont was inspectediserviced in accordance with the manufacturers' <br />guldvrines. Attached to this Cartification, is infGanalion 10,9, manufacturers' checklists li necessary to verify that this Information is correct <br />and a Plot Plan showing the layout ofmanitoring equIpmont. For any equipmoint capable of generating such repons, I have also atluichod a <br />copy of the eepod; (check OJV that appIF): ED System set-up <br />19 Alarm history report <br />Teennician Name gpnnly DavjdVVjnXter <br />Signature: <br />cm-fication No 6n3313 -U7 <br />- <br />License No. <br />Testing Company Name AFFORDA-TEST <br />Phone No : 2 744_-0113 <br />Testing Company Address- �16 �2STREET GALT. CA 115632 <br />Date of I e9linglServicing: 17 <br />MonitDring System Certification <br />Page I of 2 1 i07 <br />