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t� MONITORING SYSTEM CERTIFICATI For- Use B),AH Juriselirtions Fi7thin the.S(ate of California Authority Cited: Chcrpier 6.7, Health and Sgfel))Code; Chapter 16, Division 3, Title 23, Cali or�m This form must be used to document testing and servicing of monitoring equipment. A separate c i ati$oPffiftrt must be prepared for each monitoring system control pane by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must subntit.a copy of this form to the IocANY4Rk4NW T1gj 'THystems within 30 days of test date. PERNIIT/SER I F^ A. General Info atign C4Facility Name: t V-P L (�[ i/j C YI0, Bldg.No.; Site Address: Q 6[ lcp L s- City: P 4 . dip; Facility Contact Person: k L Contact Phone No.:(-L ) b14 17 1 Make/Model of Monitoring System: t!o S 8 Y1 Date of Testing/Servicing: _L/1't0 /09 B. Inventory of Equipment Tested/Certified Check the a r ro riate boxes to indicatespecific equipment ins ected/serviced: Tank iD: rJl� -5�`t'J „ _ Tank ID: 4r� ❑ In-Tank Gauging Probe. Model: L1 In-Tank Gauging Probe. Model: ❑-A-ranular Space or Vault Sensor. Model: Cl Annular Space or Vault Sensor. Model: LL Piping Sump/Trench Sensor(s). Model: —45 --3 i❑-Piping Sump/Trench Sensor(s). Model: , 5 -�-75 ❑ Fill Sump Sensor(s). Model: ❑ Fill Surnp Sensor(s). Model: 0--Mechanical Line Leak'Detector. Model: -j',t#0 M1...1--Z7 ❑-Mechanical Line Leak Detector. Model: D ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leal:Detector. Model: El Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page I. ❑ Other(s ecify equipment ment t e and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: 0 hi-Tani:Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 0 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: ❑ Mechanical Line Leak Detector. Model: Ll Electronic Line Leak Detector. Model: Cl Electronic Line Leak Detector. Model:. ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: to Other(specify equipment ty a and model in Section E on Page 2)_ ❑ Other(s eciFy equipment type and model in Section F on Page 2)_ Dispenser ID: / & S � / DispenserID: P I It ❑ Dispenser Containment Serisor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Cl Shear Valve(s). n Dispenser Containment Float(s)and Chain(s). a Dispenser Containment Float(s)and Chain(s). TIS Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containrment Sensor(s). Model: ❑ Shear Valve(s). 0 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 Sensor(s). Model: ❑ Shear Valve(s). C] Shear Valve(s). LIDispenser Containment Float(s)and Chain(s). 0 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 attach•d a copy of the report;(check all that appfv): ❑ Sys m set-up D Alarm history report Technician Name(print): I`�J � 2, Signature: - t J Certification No.: ( License.No.: Testing Company Name: Phone No.:( og Site Address: a�w Date of Testing/Servicing:—/—/ Page'�'+it 3 03/0I Monitoring System Certification D. Results of Testing/Servicing