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r • •E T Dispatch MONITORING SYSTEM CERTIFICkTION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safely Code: Chapter 16, Division 3, Title 23. California Code ofRegulations Phis form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each nonitorin�system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ownerioperator. he ownerioperator must submit a copy of thin form to the IocaI atienc,reguiating UST systems within 36d 2ys of rest dare. 6L. General Information �\ ,acilityName: Bldg.No.: iite Address: �(i I'� i l U lig—'.., City: 1G�—' Zip: 0( ),r acility Contact Person:_ , �� t� it ( V , V, ,e 'yl Contact Phone No.: ( 71oO -7 L4 0 '� , ✓ake/Model of Monitoring System: _( _�7 _Serial Number U ot.S 1.1 y yO sir 3 Sate of Testing/Servicing: 6. Inventory of Equipment Tested/Certified heck the appropriate boxes to indicate specific equipment inspected/serviced: rank ID: �_�-cM Tank ID: 3 In-Tank aging Probe. Model: Q In-Tank Gauging Probe. Model: ld'Annuiar Space or Vault Sensor. Model: E/1.C RM Annular Space or Vault Sensor. Model: 4 :2 Piping Sump/Trench Sensor(s). Model:t1" Piping Sump/Trench Sensor(s). Model: -'Fill Sump Sensor(s). Model:�5 ff Fill Sump Sensor(s). Model: ? Mechanical Line Leak Detector. Model: 1] Mechanical Line Leak Detector. Model: 7 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: D Other(specify equipment a and model in Section E on Pae 2). ❑ Other(specify ui ment type and model in Section E on Page 2). CankID:'j �1G. Tank ID: In-Tank Gauging 1�robe. Model: 0 In-Tank Gauging Probe. Model: 'Annular Space or,Vault Sensor. Model:_y//gyp Uo r. E3 Annular Space or Vault Sensor. Model: 21 Piping Sump/Trench Sensor(s). Model D Piping Sump/Trench Sensor(s). Model: �l Fill Sump Sensor(s). Model: L44t` D Fill Sump Sensor(s). Model: =l Mechanical Line Leak Detector. Model: ❑ Mechanical Line Lealc Detector. Model: 7 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ZI Tank Overfill/High-Levet Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: D Other(specify ui nIXanmodel in Section E on Page 2). ❑ Other(specify a ment a and model in E Dispenser ID: f Dispenser ID: S-f g ,. " !4k ;rDispenser Containment Sensor(s). Model: o� 3' ;),Dispenser Containment Sensor(s). Model:K-1? M Shear Valve(s). A Shear Valve(s). ZI Dispenser Containment Flo sand Chain(s). 13 Dispenser Containment Float(s)and Chain(s). Dispenser ID:. / ,� > Z. Dispenser ID: - . { Dispenser Containment Sensor(s). Model: t'll' _S2_T � Dispenser Containment Senso s). odel:�/✓ 22 Shear Valve(s). t Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Di enser Containment Float(s)and Chains. Dispenser ID: Dispenser ID: .Pi E61)ispenser Containment Sensor(s). Model: T7'A' .7 � tainment Sensor('Dispenser Cons). Model:y- 2 ` Shear Valve(s). �t7 Shear Valve(s). Dispenser Containment Floats 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): ,1 System set-up ,El Alarm history report Technician Name(print):J � ?EGGS / Signature: J Certification No.: C)6),4 — o, /Z l License.No.: 3 Testing Company Name; CHARLES E. THOMAS COMPANY Phone No.: ( 310 ) 323 6730 Address: 13701 So. Aima, Gardena, California 90249 Date ofTesting/Servichig:.- Page 1 of 3