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r+ • 0 MONITORING SYSTEM CERTIFICATIC[Fff/ r D `y For Use By A//Jurisdictions Within the Stale of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, CaliforniaJAtCo�� X6'69e e ons This form must be used to document testing and servicing of monitoring equipment. A separate certification or re ort lust be prepared for each monitoring system control panel by the technician who performs the work. A copy[oltjlry�( IAt1,6 h ed to the tank system owner/operator. The owner/operator must submit a copy of this form to the local ag�NHj08kRVj0 systems within 30 days of test date,-, A. General Tuformation ��, Facility Name: 5Bldg. No.: Site Address: 9'�?o W JZ*Am L, -j City: 1,a[> J Zip: Facility Contact Person: :3 -A -L— Contact Phone No.: ( ) Make/Model of Monitoring System: Ttg Date of Testing/Servicing:/ 1/ —Off Q9 B. Inventory of Equipment Tested/Certified Check the aperoeriate hoses to indicatespecific equipment inspected/serviced: Ta Tu Ic D. T: nk ID: 77 Gauging Probe. Model:z 1 Annular Space or Vault Sensor. Model y ,u Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Q� ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment t e and model in Section E on Page 2). In -Tank Gauging Probe. Model: z Annular Space or Vault Sensor. Model: �/ ,Piping Sump /Trench Sensor(s). Model: ❑ ill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other Ispecify a ui ment t e and model in Section E on Page 2). T nk ID: Tank ID: J In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: I7 Piping Sump/ Trench Sens-or(s). Model: ❑ Fill Sump Sensor(s). Model: ,6 Mechanical Line Leak Detector. Model: {0'ZO� ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill /High -Level Sensor.€ModeC ❑ Other (seeciEy a ui ment ty 2 e and model in Section E on Page 2). Xln-Tank Gauging Probe. Model• /n46 7 Annular Space or Vault Sensor. Model: q�Q Piping Sump/ Trench Sensor(s). Model:- -- ❑Fill Sump Sensors ). Model: Mechanical Line Leak Defector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank -Overfill / High -Level Sensor. Model: ❑ Other (specify equipment ty a and model in Section E on Pa Di penser ID: 1--2- Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). dd Dis eraser Containment Float(s) and Chain(s). Dispenser ID: 3-y Dispenser Containment Sensor(s). Model: /-,n Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: 5 -L Dispenser Containment Senson(s). Model: Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). Di penser ID: -- 4 Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: _ -/D Dispenser Containment Sensors). Model: 2-06ElDispenser Shear Valve(s). ❑Dis enser Containment Floats) and Chain(s). Dispenser ID: Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats) and Model: Chain(s). •lfthe facility contains more taidcs or dispensers, copy this fonn. Include information for every tank ind dlenpn.a �r d... f";rI„ -Lti Q -r_ .... 11. C. Certification - 1 certify that the equipment identified in this documenJ�tr in"cteds ed�in ec rdnL,4— 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 equip ent. For any equip: ent capable of generating such reports, 1 have also attached a copy of the report; (check n//that rrpplv): �ys m set-up 4 Alarm history report Technician Name (print): AVJ j 14 I 'n kl& ✓ Signature: f�C e0- IF 52 73-elr Certification No.:7 7%� License, No.: 17LA�: Testing Company Name: A r ra p Phone No j i-oq ) 9V4- 6112, Site Address:t/ ,r) W - y0 n�A� Date of Testing/Servicing: Page 1 of3 03/01 Monitoring System Certification D. Results of Testing/Servicing sf/