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MOP, rO SYSTEM CERT1M.ATION.91kil (S)064wx d For Use By All Jurisdictions Within the State of Cal(fornid Authority Cited: Chapter 6.7. Health and Safity Code: Chapter 16, Division J. Title 23. California Code of Regulations This form must be used to doc=wm testing and servicing of monitoring equiproent. „acate certirrcat(orkor am must be prepared for tach m2akgringjxstem 22=1 vsnel by the technician who performs the work. A copy of this form mus4-be prov�cd syFtem. c,wner/operator. The owner/operator must subttrit a copy of this form to the local agency regulatingEJ�T s�±ste�rtesuh` days of test date. A- CeneralInformation Facility Name: pfz 'c ® Bldg. No.: �tcc. �, E�,j TSite Address: Ct,i� City: �l"C Lcc, pFacility Contact Person:Contact Phone No.: (S29d Make/Model of Monitoring System U Fa Date of Testing/Semicing: �/ `Z / 0 Z B. Inventory of Equipment xested/Certifled Tank ID: L) I CA t ( Z'ln-Tank Gauging Probe. Model: ,ja' Annuls Space or Vault Sensor, Model: Z Piping Sump / Trench Sensor(s). Model: Z fill Sump Sensor(s), Model: O Mechanical Line Leak Detector. Model. Cl Electronic Linc Leak Detector. Model: O Tank Overfill I Nigh -Level Sensor. Model: O Other (specify equipment Dr and model in Section E on ?!OIL— age 2).Tank TankID: O In -Tank Gauging Probe. Model: O Annular Spacc or Vault Sensor. Model: O Piping Sump/ Trench Sensor(s). Model: j O Fill Sump Sensor(s). Model: O Mechanical Linc Leak Detector. Model: 0 Electronic Line Lcak Detector. Model: 1 O Tank Overfill / High -Level Sensor. Model: _ Dispenser ID: Z. A Dispenser Contain crit Sensor(s). fB Shear Valvc(s). O Dispenser Containment Float(s) ai Dispenser ID: J X Dispenser Containment Sensor(s). yeShcar Valve(s). Dispenser ID: O Dispcnm Containment Sensor(:). Model: O Shear Valve(:). 012iianser Containment Flog s) and Chaai!Ms). °!f the facility contains more tanks or dispensers, copy this form. Include Tank ID: O in -Tuck Gauging Probe. Model: O Annular Space or Vault Sensor. Model: O Piping Sump/ Trench Sensor(s). Model: O Fill Sump Sensor(s). Model. D Mechanical Line Leak Detector. Model: Q Electronic Linc Leak Detector. Model: • Tank Overfill / High -Level Sensor. Model: eri uipenenypc and model in Section E on Page 3). Tank ID: O in -Tank Gauging Probe. Model: Q Annular Space or Vault Sensor. Model: O Piping Sump / Trench Sensor(s). Modcl: O Fill Sump Sensor(s). Model: * Mechanical Line Leah Detector. Model: O Electronic Linc Leak Detector. Modcl: O Tank Overfill / High -Level Sensor. Model: O Other (niecify eguipnsent type and model in Section E on Pa -e Z . Dispenser ID: ��4 ,a3 Dispenser Containment Sensoria). Model:. JWShcar Valye(s). O Dispenser &atainrnent Float(s) and Chain(s). b1spenser ID: O Dispenser Containment Sensor(s). Model - 0 Shear Valve(s). ,;, O Disensser Containment Floats) and Chain(s). Dispenser M. O Dispcnw Containment Sensor(s). Model: ® Shear Valve(s). O Dispenser Containment F12sts2 and Chsin(s . - afommation for every tank and dispenser at the facility. C. Certification -I certity 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 Pian showing the WOW of mouttoring equipment. For any equipment capable of geoeraung such reports, I have also attschcd a copy of the report; (check all that apply): f riystem set-up m history report Technician Name (print):,G- Q ,tom 7�6L S Signature: Certification No.: License. No.: 0&160 Testing Company Name: Picone No.: 464_83 _ Site Address: .. Date of Testing/Servicing.. Page I or 3 Monitoring System Certification Q3/01