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MN OWINSYSTEMcEor *ATIONG3�C�C OM D For Use By.�lII Ju•rsda•lions H71hin the $lute n/Y'nli/urniu'" Authority Cited: Chapter G.7, !-/eafth cud Sgfgv C'o 1c; C'hupteu'!G, Dirtrfon 3, Tilley 73, C nitJornia Cade�CoC[f Pplegulortio9n(os�o8 o phis form must be used to document testing and servicing of monitoring equipment. A separate certiticatloUrterfOrt-ISUt be •. prepared for each monwner/orine system control pone) to the technician who performs the work. A�copy of this fgr) ' t�P the tank system owner/operator. The owner/operator must submit a copy of this form to the cal a-"e, within 30 days of test date. A. General Information Facility Name: 1'oOD y Bldg.No.: Site Address: $ /i(, W//66/1I WA City: 5' oaks Zip: 952o5 Facility Contact Person: 9.,Lj!w--r Contact Phone No.:( ) y Make/Model of Monitoring System: VEE" QpC'r - "Tj_�j.ggp Date of Testing/Servicing: B. Inventory of Equipment'Itested/Certified Cheep the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: S� QG"r Tank ID: 7- p,!, In-TankGauging Probe. Model: 13 In-TankGauging Probe. Model: An�iblar Space or Vault Sensor' Model !y�� ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: FIM ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensoi(s). Model: 2L-'� ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model:-�—� � � ❑ Mechanical Line Leak Detector. Model:i0 Electronic Line Leak Detector.. Model: p Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify a ui ment t e and model in Section E on Pa a 2). ❑ Other(s ecify a ui ment t e and model in . Tank ID: Tank ID: R1 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. MJd odel: Piping Sump/Trench Sensor(a). Model: 1] Piping Sump/Trench Sensor(s). Model: 10 Fill Sump Sensor(s). Model:--� ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model )b Electronic Line Leak Detector. Model:TT ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s eci a ui inept type and model in Section E on Pa a 2). ❑ Other(specify a ui pment t e and model i eclion E on Pae 2). r Dispenser ID: 19 i ® Dispenser Containment Sensor(s). Model: Dispenser lD;_ $( Dispenser Contaimnent Sensoria). Model: QO$ 0 Shear Valve(s). W Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 4- Dispenser ID: 19 Dispenser Containment Sensor(s). Model: 20$ ❑ Dispenser Containment Sensor(a). Model: W Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s).. Q Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 Dispenser lD: M Dispenser Containment Sensoria). Model: '2G$ El Dispenser Containment Sensor(s). Model: - 0 Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Contaimnent Float(s)and ispenss). ❑ Dis enser Containment Floats)and Chiefa i *If the facility contains more tanks ordispensers,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 a//i/mt app/y): Sy s - Alarm history report Technician Name(print):ZQN€ AL 1, Signature: Certification No.: Li `SCC 52 cense.No.:_d�T33�U7' Testing Compan/y N7 � amme:_ / rm_ TD'S_-1- Phone No.:(A09 A''S/</ —61,12 Site Address: /�7 tc & /Sp^( Date of Testing/Servicing: Page 1 of - Monitoring System Certification 03/0I A Results of Testing/Servicing