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MONITORING SYSTEM CERTIFIr"A l` yr L t .1/l.Jrni.Srli�liora� 11'i/ljin lla•.`,i,I/C ?/'('nl. U 1ulhorih•' C'ilcrl: ('hrt/.Ncr G.7, /A ..r uiicl.SiiJ�lt' C'urli; ('hcr/�lcv 16, L)ii•i.tiion 3, 7W 2.i, ( U or C 1, c, Ewliv This folm must be used to document testing and servicing of monitoring equipment. A separate certification or ret�ortmust he prepared for each monitoringsystem control panel by the technician who perf;��s the work. A copy of this f t rat •t the tank system otivner/operatored in . The owner/opera(or must submit tr copy of this form to the local 1`�Cllcy r"LiT.it�`- � Systems A. within 30 clays of test date. f_ SAN JOAQUIN COUNTY A. General Information Facility Name: �p , ENVIRONMENTAL T LTH DEPARTMENT c g. o.:_ Site Address: -- City: Zip: s-706 Facility Contact Person: �,G/fj�/� Contact Phone No.: ( oma► Make/Model of Monitoring System: VDate of Testing/Servicing: / d q/ P, B. Inventory of Equipment Tested/Certified Check the a , ro ,rime boxes to iudic;rte s eeific ec ui went inti eeted/seiviced: Tani( ID: Model: �U In -Tank Gauging Probe. Model: 10 Annular Space or Vault Sensor. Model: $h Piping Sump / Trench Sensor(s). Model: 2 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leal: Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pa a 2). Tank ID: Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model- ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank 11 Dispenser ID; ❑ Dispenser Containment Sensor(s). Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecify a ui . ment ty a and model in Sect irni E on Page 2 ). Tank ID: "'If the facility contains more ranks or dispensers, copy this form. Include information for every tante and dispenser at the facility. ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: I, ❑ Other (specify a ui ment type and model in Section E on Pap 2). Dispenser ID: (� 9P Dispenser Containment Sensor(s). Model: Dispenser ID; ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis eraser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis. enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Sensor(s). Model: ❑Dis enser Containment Float(s) and Chain(s). ❑ Shear Valve(s). Cl Dispenser Containment Float(s) and Chain(s). "'If the facility contains more ranks or dispensers, copy this form. Include information for every tante 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; icheck all that apply): K System set-ulAlarm history report Technician Nam'7e (print): We Signature: Certification No.: &Z 52y; .33 2 % U r License. No.: C3�� tX�`�-1C ,7l Testing Company Name: eI4� Phone No.:�,��)�:y.�/ Site Address: Date of Testing/Servicing: 9 /011 /0 Page I rrf3 o3/Dl Monitoring System Certification D. Results of Testing/Servlj�ing SS C_