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• Dispatch MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7Health and Safety Code; Chapter 16, Division 3, Title 23, Cal�fornia Code of Regulations Chis form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each nonitorinE system control panel by the technician who performs the work. A copy of this form must be or to the tank system owner operator. Che owner/operator must submit a copy of this form to the local agency regulating[IST systems within 30 days of test date. �. General Information ! ?acility Name: �c CBldg.No.: lite Address: � City: 1 t� i �� Zip: G c� ;acility Contact Person: 1 '�? u �' i Contact Phone No.: (. 6U ) - vlake/Model of Monitoring System: i L -��O>z'�+, v Serial Number 0 S 13 y 4i S s Z S76 C'7 Date of Testing/Servicing: ry / 12 /C,6 `` n 3. Inventory of Equipment'Tested/Certified l heck the aggropriate boxes to indicates ecific a ui ment inspected/serviced: rank ID: l i if S u t7k.T Tank ID: '7-2- 0 7 L�n �e 7 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: � Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model:_ 3-Piping Sump/Trench Sensor(s). Model: 7 94`3�3G —,3 3 U-Piping Sump/Trench Sensor(s). Model: 7 9 Y�rC .- 3 2 3 A-Till Sump Sensor(s). Model- `7?�,; > .3 I-Fill Sump Sensor(s). Model: "7$c/3 - L t D Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: J Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: � Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: :I Other(speciiv equipment tyDe and model in Section E on Page 2). ❑ Other(s ecify equipment type and model in Section r,on Page 2). Tank ID: Un z.ctcU S v Tank ID: c� o. :3 In-Tank Gauging Probe. Model: ❑ I tk Gauging Probe. Mod 1. Z) Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 3'Piping Sump/Trench Sensor(s). Model: 2`✓`1 8 C'�3 3 L�!'Piping Sump/Trench Sensor(s). Model: 7 `/"/3~i',U 3 .j 3-Fill Sump Sensor(s). Model: 71`%3 8C` 3 L 5 a-Fill Sump Sensor(s). Model: -7`i`13 FA L' "-3 Z Z) Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: � Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify e ui ment a and model in Section E on Page 2). ❑ Other(s ecify equipment type and model in Section E on P e 2). Dispenser ID: 42 Dispenser ID: 3 2 3 ❑ Dispenser Containment Sensor(s). Model: e/`t 3�0 —,3 Z 3 ❑ Dispenser Containment Sensor(s). Model: /7'Y380 ZI Shear Valve(s). ❑ Shear Valve(s). ZI Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: 5 C __ LODispenser er ID: 7 S ❑ Dispenser Contai ment Sensor(s). Model: ?`I�%3 Ci Containment Sensor(s). Model:3 Shear Valve(s). Valve(s). � Dis enser Containment Float(s)and Chain(s). nser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: :1 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ZI Shear Valve(s). ❑ Shear Valve(s). ]Dispenser Containment Float(s)and Chain(s). ❑ Dis enser 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 that apply): [-System set-up Ua-7Kfarm history report IA Technician Name(print): ( f –7 C - /. O Signature: :ertification No.: A S 1 –11 -7 License.No.: 302015 Testing Company Name: CHARLES E. THOMAS COMPANY phone No.: 310 ) 323 6730 kddress: 13701 So. Alma, Gardena, California 90249 Date of Testing/Servicing: G Page 1 of 3