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MONARING SYSTEM CERTIFPATION For Use By All Jurisdictions Within the State of California S Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code Rggg dations— This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must bettali for each monitoring system control panel by the technician who performs the work. A copy of this form #,b��;p ovided t" system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating US std -was within 30 days of test date. �' 4 6 A. General Infi Facility Name: #4 Site Address: cation 4r— & 83 City: Aj Bldg. No.: Zip: C�rj Facility Contact Person: Contact Phone No.: ( �) Make/Model of Monitoring System: 1l�_Pnel A -C-% 1 z. " 34 1 ' Date of Testing/Servicing: /7/ B. Inventory of Equipment Tested/Certified —__,..,..... , . t incnevted/cerviced: *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the tacility. 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 iation is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such repo s, I a ,e -also attached a copy of the ort; (check all that�pply): I System set-up '.4k Al .�m'fiistory repo Technician Name (print): Signature: Certification No.: License. No.: Testing Company Namef 'Ale : Phone No j ze, . / '<< ' 7 Site Address: Date of Testing/Servicing: -/ 12' ,-?— Pagel of 3 03/01 Monitoring System Certification Tank ID: 7 A%1lG�j��. Tank ID: A In -Tank Gauging Probe. Model: r1 In -Tank Gauging Probe. Model: %1-- Annular Space or Vault Sensor. Model: �f O G" PD Annular Space or Vault Sensor. Model: - 4v` f� Piping Sump / Trench Sensor(s). Model: - " '-D X (A Piping Sump / Trench Sensor(s). Model: J ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line beak Detector. Model: F - l !H Mechanical Line Leak Detector. Model: Ex ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment t)Te and model in Section E on Page 2). ❑ Other (s ecif equipment t `e and model in Section E on Pai;e 2). Tank ID: 5At'ipz Tank ID: "%� ❑ In -Tank Gauging Probe. Model: �? In -Tank Gauging Probe. Model: 1�k Annular Space or Vault Sensor. Model i A757M ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model•J El Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: El ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Mode(; _ ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment t e and model in Section E on Page 2). ❑ Other (specify equipment t e and model in Section E on Page 2). Dispenser ID: Dispenser ID: 2 •'— ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Conf ainment Sensor(s). Model: lS Shear Valve(s). W Shear Valve(s). A Dispenser Containment Float(s) and Chain(s). �11 Dispenser Containment Float(s) and Chain(s). Dispenser ID: - Dispenser ID: .7 _<_ ❑ Dispenser Con inment Sensor(s). Model: ❑ Dispenser Co tainment Sensor(s). Model: ® Shear Valve(s). 59 Shear Valve(s). Dispenser Containment Float(s) and Chain(s). 51 Dispenser Containment Float(s) and Chain(s). Dispenser 1D: 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 tacility. 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 iation is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such repo s, I a ,e -also attached a copy of the ort; (check all that�pply): I System set-up '.4k Al .�m'fiistory repo Technician Name (print): Signature: Certification No.: License. No.: Testing Company Namef 'Ale : Phone No j ze, . / '<< ' 7 Site Address: Date of Testing/Servicing: -/ 12' ,-?— Pagel of 3 03/01 Monitoring System Certification