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MONI#WNG SVSTEM CERTIFIOTI&Ct-, ,CC 1,F Tor (!sc 81,.I//Jnrisdiclions f1'ilhin the ,Slule nfC'nl�/ixllhl ,4ulhorily Cited: C'hgjver 67, Heallh Code; C'hah/ur 16, Dirisi0r7 3, Title 23, C'nlifi�rnic lc, �� alis This form must be used to document testing and servicing of monitoring equipment. A separate certification or rexprt must be Mepared for each monitoring system control panel by the technician who performs the work. Acopy ti tlils#�ll}nn 1 dst b"f1W0d� ed to the tank system owner/operator. The owner/operator 111USt submit a copy of this form to the local systems within 30 days of test date. A. General Information Facility Name: "4-rpS Lt"� l2 AS Bldg.No.: Site Address: /5-3(e /V• itI✓YE S7 City: :S-rbc4zmpl� Zip: Facility Contact Person: XA it t.- 40 t Contact Phone No.: (_2&7 ) q4e- f (03(p Make/Model of Monitoring System: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate ro ate boxes to indicates cciiic et ui ment ins ected/sewiced: Tank ID: 17/ Tank ID: g� D In-Tank Gauging Probe. Model: /L7E?(�/ a h1-Tank Gauging Probe. Model: MA 6r M Annular Space or Vault Sensor. Model: �� 11 Annular Space or Vault Sensor. Model: Zo Ig Piping Surnp/Trench Sensor(s). Model: to ® Piping Surnp/Trench Sensor(s). Model: Zoe ❑ Fill Sump SenSOr(5). Model: El Fill Sun1p Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: L3 Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model L-`D ® Electronic Line Leak Detector. Model:_ 6� ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment t pe and model in Section E on Page 2). L1 .Other(specify e ui.rent type and model in Section E on Page 2). Tank ID: S7C0 Tank ID: DIF- A In-Tank Gauging Probe. Model: AIA / W In-Tank Gauging Probe. Model: N/A Ug Annular Space or Vault Sensor. Model: 20 li Annular Space or Vault Sensor. Model: KI Piping Sump/Trench Sensor(s). Model: 706 I&L Piping Sump/Trench Sensor(s). Model: Zd$ ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 191 Electronic Line Leak Detector. Model: PLS &Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfiif/High-Level Sensor. Mo ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment ty e and modeon Page 2). Dispenser lD: I 1� Z Dispenser lD; -1 't-S ® Dispenser Containment Sensor(s). Model: 4e - col l8 Dispenser Containment Sensor(s). Mod60 1 ® Shear Valve(s). jel-Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Cha Dispenser ID: -_j w--f Dispenser ID: � -V (O A Dispenser Containment Sensor(s). Model: V4- - 001 �--Dispenser Containment Sensor(s). Mod=je ��® Shear Valve(s). M-Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Floats)and ChaDispenser ID: S'� Dispenser ID: r ( -t 11L6 DispenserContainmentSensor(s). Model• r/Q- c-1 ®-DispenserContainmentSensor(s). Mod - poWShear Vatve(s)• &Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chai *If the facility contains more tanks or dispensers,copy this fon». Include information for every tank and dispenser at the facility. 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 information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that appl)): aSystem s t-u Alarm history report Technician Name(print):--ZAwp /y;,. -'n Signature: r Certification No.: License.No.: W 52 33 2-7 U 7" -6Z-L7L 9 Ozi -I&7b 14 Testing Company Name: ./ - Tcsr Phone No j-20 )7 J Site Address: 1536 2 --s Date of Testing/Servicing: 7/t�/ Page 1 of 3 03/01 Monitoring System Certification D. Results of Testing/Servicing