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MON#)- RIN,G SYSTEMCERT IFI '�� _1 -� ,,` ,__ Esc Gt�.l// /ur isr(iction.r !1"iIl�irr Ilre.S7cNe of Ca/r r „iu � L QJ� Awhorily C'ilecl: Clicrpler 6.7, l-leallh u;n/Suf�ly C'ucle; C{7upler J6, Division 3, Tillc 23, Ccrlifbrniugg��Cocic Qf Rc,rrlalinjzr This form must be used to document testing and servicing of monitoring equipment. A separate a9fi@at nrQreport must be prepared for each monitorinn system control panel by the technician who performs the work. A co �q�� tR f an vided to the tank system owner/operator. The owne!�operator must submit a copy of this form to the �t)y systems within 30 days of test date. P , � ��IV16661 L A. GeneralInfoKmation Facility Name: ([a�1��!/" )dc— Z f► 1 &JAY-) 7 Bldg.No.: Site Address: /Cf�/ �� -��J �'� Ci ry h'�_ !-�(�C� I Zip: Facility Contact Person: IC' Contact Phone No.: ( 7(1j Make/Model of Monitoring System: -7TD Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check t ie a2propriate boxes to indicatespecific equipment inspected/serviced: Ta k ID- 82 6 C T: k 1l) r c. In-Tank Gauging Probe. Model 71Tank Gauging Probe. Model - Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: )` Piping Sump/Trench Sensor(s). Model: G• )d Piping Sump/Trench Sensor(s). Model s ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: J` w Al& Mechanical Line Leak Detector. Model:_�( / V ❑ 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 Tent type and model in Section E on Page 2). ❑ Other(s ecify e ui ment type and model in Section E on Pa e 2). TTa��4k ID: t-- Tank ID: l,YIn-Tank Gauging Probe. Model: 1 ❑ In-Tank Gauging Probe. Mode �j nnular Space or Vault Sensor. Model: 5 1 B ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:- �°Tj / ❑ Mechanical Line Leak Detector. Model Cl < g I 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 type and model in Section E on Page 2). ❑ Other(s ecify e ui Tent type and model in Section E on Page 2). Di penser ID: D' pcnser ID: Dispenser Containment Sensor(s). Model: ispenser Containment Sensor(s). Model: Shear Valve(s)• hear Valve(s). ❑ Dis eraser Containment Float(s)and Chain(s). ,ZS❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s M el: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)a hain(s). ❑ Dis eraser Containment F s)and Chain(s). Dispenser ID: Dispenser l D: ❑ Dispenser Containment Sens •(s). odek ❑ Dispenser Containm t Sen r(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 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 Mal apply): ❑ System set-up ❑ Alarm history report Technician Name(print): 41Signature: ao,n vV an�,irf SLC _ - L,,4- Certification No.: I`>.�`�`1 License.No.: � Testing Company Name: itti-Lnr Phone No.: Site Address: ,�� r�� `�' ? –/4`> ( Date of Testing/Servicing: Page I of 3 03/01 1Vlonitoring System Certification A Results of TTestina/Servicing;