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EIV E' . MONARING SYSTEM CERTIFIRTIONREC For Use By.-111 nris•clictions•iVithin the State cif California Authority Cited: Clrcipler 6.7, Health and Safety Code;Cha/iter 16, Division 3, Title 23, California Cocle of Re ulallorzs This form roust be used to document testing and servicing of monitoring equipment. A separate certification or replort n�rs�t99 om prepared for each monitoring system control panel by the technician who performs the work. A copy of this form r ftIP"7y detl to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulatt within 30 days of test date. °`j NEALTH ENTAL DEpA�iT11�ENT A. General Info 1tlation Facility Name: r ) % t Bldg.No.: Site Address: f y 7 21 f /*yCity: ) Zip: " Facility Contact Person: EDD le., Contact Phone No.:( A } 9�-- 3 Make/Model of Monitoring System: "f Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to indicates specific a ni anent inspected/serviced: Tank ID: 37&ct Tank ID: in=Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model Li,0 ❑ Annular Space or Vault Sensor. Model: SPt/ Piping Sump/Trench Sensor(s). Model: W'Piping Sump/Trench Sensor(s). Model. 27L?d' ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Defector. Model: A Mechanical Line Leak Detector. Model: �000 ❑ Electronic Line Leak Detector_ Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model. ❑ Other(specify equi meat ty e and model in Section E on PaLe 2). ❑ Other(specify a ui meat t )e and model in Section E on Pae 2). Tank ID: Tank ID: In-Tank Gauging Probe. Model:_ ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Id'Piping Sump/Trench Sensor(s). Model:---;; tf ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:LjO 0Q _ ❑ Mechanical Line Leak Detector. Model: " ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Levet Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecif:e ui nnernt t ape and model in Section E on Page 2). ❑ Other(s ecify equipment t e and model in Section E on Page 2). at Dispenser ID: Dispenser ID: iO�fa�Dispenser Containment Sensor(s). Model: -zp_& Dispenser Containment Sensor(s). Mode c.3' l Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s)_ Model: ❑ Dispenser Containment Sensors) Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser iD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment.'cnsor(s)_ Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser 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 facility. C. Certification - i certify that tine equipment identified in this document was inspected/serviced ill accordance avith the rnanufacturer:s' gnidelines. ,Attached to this Certification is information (e.n. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan shopvhag the Layout of monitoring equipanent. For any equipment capable of generating such reports,i have also attached a copy of the report;(check all that(1j)p4j9: ❑System set-Ill) ❑ Alarm history report Technician Name(print) v, Q 4 t l „/k j.. Signature: �_ e Certification No.: ;7__ License.No.: - Testing Company Name:_� [ Phone Noj 'c Site Address: �� _ Date of Testing/Servicing: /,? 1,9 Pagc t of3 (13/01 Jtlonitoring SystcsaaCel tilicaati«n a_r 5-1 31-1