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MONITOUNG SYSTEM CERTMCATION • For Use By All Jurisdictions Within the State of California Azahon'zy Cize& Cliapter. 6.7, Heahh and Sqfkpi Code;-nalpfer- 16, Division 3, 72de 23, California Czwi of Raguiximu This form' must be used to document tesung and servicing of monitoring e*pment. A separate certification or report IMSt be prepared ibr each monitoring system control panel by the technician who periorms the work. A copy of this form must he provided to tine rank swstcm owner/operator. 11c ownerloperator must submit a copy of this orm to the local agency regulating U IST systems within I() days of test date. A. General Informadon Facility Name: C A-?- v V j A Bldg, No.: Site Address: q'T'7 /U. 1 ,1. Isek% WAY City: Zip; Facility Cantact Penson: JL", � t, /I iz, 5- le Contact PhCM No.:(2-02) 1Y MakeA4,odei of MortWoring System: 7 -Lf- XZ Date of Testing/Servicing: B. InTentmy of Equipment Te5tediCardfied Chat ft apprapdate basai to fimficame speeft ammmmt • I M. — I :K� - — T. m. �o.Tank Clutging Probe. Modek S- "C6, 1- Czmgmg Probe. Model: KA; u(ar Space or Vault Sensor. Model- o>ItMa- �Anmlar Space or Vault Sem Piping Sump / T=ach Sensor(s). model: alpiping, Sump / Txench Serw*s). model: U�Sump Seasons). Ubdek L3 33R Samp Sc=R*s). luodei: 9 Mechainct I= Leak Detector Model- 3 7? 2Mechanical Line LrA Detector ModeL67 0 Electronic Line Leak Derector. Modek Q Electumic Line Leak Detector. Model - C3 Tank Overfill t ffigh-Leval Sons". model: 0 Tank Overfill i high -Levet Sensor. Model: Q Other (soecifv equipment type and model in Section E on Page 2). Q Other ( and model in Section -E on Paw'-,). Tank.11D.- Tankm. 13 In -Tank Ganging Probe. model: 13 In -Took Ganging Probe. Model: - 0 Armular Space or Vault Sensor. M.A)deL- 2 -Annalar Space or Vault Sensor. Maki: 0 Piping Sump / Tumch Sensor(s). Modei- Q Piping Sump I Trench Sensor(s). Modet- C3 r -in Sump Seasons). Model., :2 Fill Simp Sensor(s). M—ndeL 3 Mechanical Line I=k Detector. Model: 13 Mechanical Line LA=k Dawor. Model - Q Electronic Lim I&& Detector. Model, 0 Electronic Line Leak Detector, Modet U Tank Overffl I ffigh-Level Sensor. Model: ED Tank Overfill / N*4,evd Sensor. Model: 0 Other aff,2—mnl and model in Section Bon 2). ca Other (specify MT -m _ent pM and modal in Secdon -E on piyormw in: ,W)Mpensa Containment Scasor(s). Model: Dhwftww MI.- �cnser C Sensorts). N&dej. 7.3a 112- - ic I irShear valve(s). Shear Valve(s), M Dispenser Containment Float(s) and Chain(s), U Dispeasa Containment Float(s) and Chain(s). W� - I Dispenser W. - -?� � sot s). Model: 330,2J —10e Dispenser containment Sensor(s). -model: Shear Valve(s). Q Shear Vahe(s). Q DW3eoser Contaimnent Float(s) and Chainis). Q DiM!!ser ConminxncntF1oat(s) and Chain(s). Diwousev wi;, S:f:qz owpoosm-m; ,�X,Pispcnscr Containment Seasor(s). model: 'ErSbear Q Dispenser Containment Sensor(s). Modrh Valve(s). L3 Shear Valve(s). Unspenser Containment Fla*s) and CbmWs) 13 Die Containment Float(s) and Chain(s). 'if dhc &cflky contams mom tanks or dispensers, copy ids form. Include adonnation, for every tank and dispenser at the focality. C. Cartification - i ea -ay that *a equipanwAideniffitedia *6 dociameat ,ras ias�,-ia mwordwme " Ike mmofteWreW goideffum Attached to this Cartilication is infornotim (e g. icier cheddists) aecessary to vft* that this infonnation is correct and a Plot Plan showing the layma of manitering eqmpmeuL For any equipment capable of generating such rep", I have also attached a copy of the'anniv J: :I System sett Technician Name (print):77jC-7Zv� r Signature. cartification No.; License. No.: T Testing Company Name: LtiA K?10 '� FREQ51bl':' Ji4 10 k -r -7," N C Phone (moi -C^ - 2-7 5 ne NO.. Address: P- Date of Testing/Seractag: Page I (if 3 'VIonitoring System Certiffeation