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MONITORING SYSTEM CERTIF*kTION lseJurisdiction ),Vilhin the State of Cal junvia Aathorily Cired: Chapter 6.7, /-lea th and S'afgv Code; Chapter 16, Division 3, Tille 23, California Code of RegalationV This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be there ared for each monitoring system control panel b the technician t ;�W�p/, o of this form must be provided to tank system owner/operator The owner/operator must submit: t �i I l cal agency regulating UST sygUis -� within 30 days of test date. A. General Information Dltt ZUO8 Facility Name: Vv ✓1 -e a w p4k-1 p41—1 76 Bldg.No.: Site Address: 1 C. K EN �•� Zip: S;P-414) Facility Contact Person: ' raj LP M s-f N 1 FRId� n act one No.: Make/Model of Monitoring System: (' I ( ba n--d) /W 7 C Date of Testing/Servicing: L;Ul7 1-!�7 B. Inventory of Equipment Tested/Certified Check the aroriafe hoses lu indicates specific equipment ins ected/serviced: Tank ID: Tank ID: 4 In-Tank Gauging Probe. Model: Z �Tald Gauging Probe. Model: /97A'G2- J21 Annular Space or Vault Sensor. Model' CB A nular Space or Vault Sensor. Model:— 'X Piping Sump/Trench Sensor(s). Model:� WPiping Sump/Trench Sensor(s). Model: a-O ❑ Fill Sump Sensor(s). Model: ❑ tunp Sensor(s). Model: ,C(Mechanical Line Leak Detector. Model: CJ 8-OOD Cil 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 equipment a 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: sPS-E r ❑ In-Tank Gauging Probe. Model: ®-W-Tank Gauging Probe. Model: Yh/Ag Z ❑ Annular Space or Vault Sensor. Model: ❑��Ami plar uSpace or Vault Sensor. Model: er" C3 Piping Sump/Trench Sensor(s). Model: IrViping Sump/Trench Sensor(s). Model: D ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Defector. 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 eci equipment t e and model in Section E on Pae 2). ❑ Other(specify equipment[ e and model in Section E on Page 2). Dispenser ID: I G>L ^Z Dispenser ID: ❑ Dispenser Containment ensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: �. C3Shear Valve(s). ElShear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats)and Chain(s). Dispenser ID: --i tA-1 Dispenser ID: 7� El Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dis nser Containment Flont(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). "I I'the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispense atVie facility. C. Certification - I certify that the equipment identified n hl� ocurtfent s i spe ht sf7,4v/0 f-o eerd' ce 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,l have also attach d it copy of[he report;(check rrll that app/y): ❑S em e 1) 13❑ Alarm history report Technician Name(print): J�a ,n, �y�mmn Signature: Y/ -�� '/` 40 Certification No.: n/n(}ej License.No.. �U //ry Yj ,/ Testing Company Name: �nr I-) �P S�' Phone NoA og ) �ry4-o WL Site Address: Date of Testing/Servicing:—/—/— Page 1 ofd _ 03/0I Monitoring System Certification D. Results of Testing/Servicing SAL