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MONIJORING SYSTEM CERTIFI*TION For Uve &.41 urisdicllons hVilhin the Stale of California Aillhorily Cited: Chapler 6.7, Heahh and S'gfety Code; Chaplcr /6, Division 3, Tide 13, California Code oj'2egulnlions• This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form mist p d [G� the tank system owner/operator. The owner/operator must submit a copy of this form to the local agenzQa� �IinA&IS t M within 30 days of test date. A. General Information FacilityName: nnlAr!-1, Site Address:/ t WW' Wy C, `/ZtJ y �-ia City: 41 1 i1oleI /, Facility Contact Person: Snq.4 Contact Phone Make/Model of Monitoring System: `J e fG).P r k B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauinment insmcted/servicwL- SAti ; aAC<J'-" COUNT Y ENVIRONMENTAL lint@ it" P Et A R T tiitll r. , — Zip: 9.6-;: 2- C Date of Testing/Servicing: a'22_07 Tank ID: 6r.f— k ID: L In -Tank Gauging Probe. Model: � Gauging Probe. Model:Annular Space or Vault Sensor. Model:t/ZDnnular fn-Tank Space or Vault Sensor. Model• �iPiping Sump / Trench Seasons). Model: 249.4ping Sump / Trench Sensor(s). Model: 7Oa >ff Fill Sump Sensor(s). Model: 2aR ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: y n Z�C70 Kvlechanical 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 (s ecif equipment t e and model in Section E on Pae 2). ❑ Other (specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: In -Tank Gauging Probe. Model: mlA h 1 ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: t f J D ❑ Annular Space or Vault Sensor. Model: 1K Piping Sump / Trench Sensor(s). Model ❑ Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 7JBS ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LD 2b00 ❑ 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 equip pent type and model in Section E on Page 2). ❑ Other (specify a ui ment t e and model in Section E on Page 2). D'Spenser ID: / `' Z Di enser ID: �7 Dispenser Containment Sensor(s). Model: 24G Dispenser Containment Sensor(s). Model: Z ro Ll Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). Di penser ID: 4 (p Dispenser ID: 7f Dispenser Containment Sensor(s). Model Z )a Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). enser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). enser ID: 'f Dispenser ID: // F Zispenser ris Containment Seasons). Model• Zoo CxDispenser Containment Sensor(s). Model: 2ohear Valve(s). ❑ Shear Valve(s). s 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 rlisnpnspr nt flip f ril;ro C. Certification - 1 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 Plat Plan showing the layout of monitoring equipment. For any equipment capable of generating Stich reports, l have also attached a copy of the report; (c/reek al/ their app/v): KISyst se �/ I'd larm history re ort Technician Name (print): �,U IP M;l p Iml Signature: M �y L't.0'a -le, Certification No.: �f'' -,� C9T�O 0 ,� License. No.: O a — /1X•/ -5 Testing Company //Name: t TOZ1lA IC 5-t PhoneNojzo )Wgoi )q Site Address:Ylb 2riD C+rr_-Cf Date of Testing/Servicing,03 /_7`)i/'97 Pagel of3 _ .A Monitoring System Certification D. Results of Testing/Servicing a- V 03101