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ry �NRECENEDD FoMOIN' r Use BV A//JurlsdiL't1011s Within the,State ofC'alilor•niu .4uthority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Cali bt niu Coe1 j o N c�arl2 21 608 This form must be used to document testing and servicing of monitoring equipment. A se crate certification or report 1isUt`be �tepared for each monitoring system control panel by the technician who performs the work...A copy of th�SQ �� / y�� PY g y KRU11 ms the tank system owner/operator. The owner/operator must submit a co of this fsii to the local a enc within 30 days of test date. A. General Information Bldg.No.: Facility Name: �... ty: ° Zip. Site Address: " d , . ✓ r,y t. Ci �.,. Contact Phone No.:( ) Facility Contact Person: Date of Testing/Servicing: Make/Model of Monitoring System: .*' B. Inventory of Equipment Tested/Certified Checle thea roriate boxes to indicates ecilic a uipment ins ected/serviced: -j Tank l D: Tank ID: � • �^ 0'ln-Tank Gauging Probe. Model: rff n-Tank Gauging Probe. Model: mlar Space or Vault l: D ❑ nl�ulm Space or Vault Sensor. ❑ Model: ,�IIVlt Snsor. Mode , ❑^°Pping Sump/Trench Sensor(s), Model: t? O'lsiping Sump/Trench Sensor(s). Model: Model: LIModel Fill Sump Sensor(s). ❑ F�U�frump Sensor(s). �3 p�'Mechanical Line Leak Detector. Model: W 'D echanical Line Leak Detector. Model: E' ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(s ecify a ui ment ty e,and model in Section E on Page 2)• Tank lD: Tank ID: �-- ❑ In-Tank Gauging Probe. Model: L�1n-Tank Gauging Probe. Model• ❑ Annular Space or Vault Sensor. Model: C�'�nnular Space or Vault Sensor. Model: .a ❑ Piping Sump/Trench Sensor(s). Model: 0, i-ping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Model: ❑er'jJl Sump Sensor(s). �.,! ,+may ❑ Mechanical Line Leak Detector. Model: p 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(s pecif a ui ment type and model in Section E on Page 2). ❑ Other(s ecify e ui ment ty a and model in Section E on Page 2). (specify _�� y �I _ Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). s ❑ Shear Valve(s). � ; l�r�° ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Disenser Containment Sensor(s). Model: Ll Dispenser Dispenser Containment Sensor(s). Model: ❑ Shear ser C s). ❑ Shear Valve(s). El Dis enser Containment Float(s) and Chain(s). Ll Dispenser Containment Floats)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 Float(s)and Chain(s). ❑Dis enser Containment Float(s)and C.hain(s). {11'the facility contains more tanks or dispensers,copy this tone. Include information fq every� tapk a�dispenser 411- f i ity. ' f- d in h the C. Certification - I certify that the equipm Certifint cation is infoified rmation tion (e�g.his mmanufa►etuiersent was ee^h`e—cklists)necessary to verify tht t this manufacturers' guidelines. Attached to this Cer kggneratin such information is correct and a Plot Plan showing the layout of monitoring equipment. F r any equipnAj ca histor rer g I have also attach d a copy of the report;(check all that npplV): ❑ Syste et y P reports, /� r mm� Signature: Technician Name(print):_j ii , License.No.: Certification No.: (i(ol� _Phone Noj ,� 517Og � D Testing Company Name: Date of Testing/Servicing: _// 3/0,9 Site Address: Q3/01 Page 1 of d Monitoring System Certification D. Results of Testing/Servicing