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Mfl . RING SYSTEM CERTIFOATIQN RIMMED For Use By All Jurisdictions Within the State of California ,Authority Cited: Chapter 6.7, Health and Safer!Code; Chapter 16, Division 3, Title 23, Califon;ia Code of Pae 1Nt 4 5 20xZ This form must be used to document testing and servicing of monitoring equipment. A separate certification or re. ftqES ALTH for each monitoring system control panei by the technician who performs the work. A copy of this form must be prp� system owner/operator. The awmer/operator must submit a copy of this form to the local agency reguiatinb LIST 5lys em days of test date. ;i. �Tl'll Cl.31 AL.:�l iYi al is V. ;r.:lity Name: Bldg. No.:Site Address: .4 zy fits-Z26 zZii{✓- City: - 7, C -_ Zip: Facility Contact Person: ' <Z 4 L C__`Y L S Contact Phone No.: �) Make/Model of Monitoring System: i L J ,' S c' Date of Testine/Servicing: 1 '' L l02—_ B. Inventory of Equipment Tested/Certified Check the a ronriate boxes to indicate s ciFic a u9 ment las ted/serviced: Tank ID: t fit/To Tank ID: 0 XTTank Cnuging Probe. Model: ❑ In_Tank Gauging Probe. liodel: of nular Space or Vault Sensor. Model: G`1`l cf 3 Z0'-2p 5 El Annular Space or Vault Sensor. Model: ` .�./Pip:,ig Sump I Trench Seasor(s). �1ode1: C� 'Zl?-;d y ❑ Piping Sump I Trench Seusorfs). _Model: ❑ rill Sump Sensor(s). Model: ❑ Dill Sump Sensor(s). Model: ❑ 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 I High-Level Sensor. 'viodel: ❑ Other(s ecifv e ui ment La and model in Section E on Page 2). ❑ Other(s ecify e ui mcnt tM2 and model in Section E on Pa a 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ 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: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. ~Model: ❑ Other(specify equipment R and model in Section E on Page 2). ❑ Other(s ecifv a ui tnent tti and rr_odel in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). ~Model: ❑ Dispenser Containment Sensor(s). NModel: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser 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). ❑ Shear Valve(s). ❑ Dispenser Containment Floatfs)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Seasor(s). Madel: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valvc(s). ❑Dispenser Containment Float(s)and Chain(s). ❑ Dis ,nser Containment Floatfs)and Chain(s). 'If the facility contains more tanks or dispcnacts,copy zli:a forth. Include infor:.-_,_; n fcr every tank and aislpcnser at the facility. C. Certification-I cerlif7 that the equipment idenlilied in this document was ins pec led/sery iced in accordance with the manufaclurers' 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 monit6ring equipment. For any equipment capable of generating such reports,I have also attached a copy of the reports( eck all that apply): ❑ System set-up ❑ kjarmrhisto re rt S Technician Name(print); � �✓� Signature: Certification No.: Y 2,} License. No.: Testing Company Name: ( ri�ttit1 'f Phone No.:( L:�C�� /f CJ ~c/ C/4�'3 Site Address: .��f.), tl�v` / �L� S �� S.� �_<� �/5 �! � � xDate of Testi ng'Servicing: Oo 2— Page I of 3 03/01 Monitoring;system Certification