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' T Dispatch MONITORING SYSTEM CERTIFICkTION For Use Bit All ,iurisdiciions T1 ithin the State of Caltornia Authority Cited Chavrer 6. Health and Safety Code; Chapre- 16, Division Titie 23, California Code of Regulations This form must be used to document tesiins and servicing of monitoring equipment. k separate certification or report must be urenared for each TOM systerr control nanel by the teenniciap. who performs the wort:. A cop^ of this norm. must be provided to the tans. system ownerioperato:_ Tne owner/operator must submit a copy of this form to the local agency reguiming UST systems within: 30 days of test date. A. General Informafion Facility Name:! VI '.L'` Bldg. No.: Site Address: 1=/_ �� iL �`,' �1 \� �:. - City: -1. ;�*'�C 1, Lei Zip; �'t( Facility Contact Person: !'Nrh, -L0641;, <' . Contact Phone No.: (zq) Li Make/Model of Monitoring System: 1,1-1 zz S Ste' Serial Number F 06 11, 162 y Ute: j C1vC� Date of Testing/Servicing: B. Inventory.,of Equipment Vested/Certified a 6 . t.. ...iir.♦> :Rr nt inertPA/carvnrrri• Y7Y y uV^" 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: ;a -Piping Sump / Trench Sensor(s). Model:t/�% ?7 ;�_ 56Piping Sump / Trench Sensor(s). '1] Model: /' 3 2 U Fill Sump Sensor(s). Model:y//{ 9213 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 / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (speciA, equipment a and model in Section E on Page 2). ❑ Other (2:.cif- equipment type and model in Section E on Page 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: i/ ' " ❑ 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: Cl Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill. / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other ( ecifv a ui ent a and model in Section E on Page 2). ❑ Other ( ecifv equi ment a and model in Section E on Page 2). Dispenser ID: 1& y 31 y Dispenser ID:- Dispenser Containment Sensor(s). Model: :� Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Di enser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: � /I` C_� Dispenser [ Dispenser Containment Sensor(s). Model: �l Dispenser Containmeni Sensor(s). Model: Shear Valve(s). P Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ DiTenser Containment Float(s) and Chain(s). Dispenser ID: / ,? // L?-- Dispenser ID: ': ,51 Dispenser Containment Sensor(s). Model: 1Z Dispenser Containment Sensor(s). Model: Shear Valve(s). P Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s). ❑ Dispenser 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 Pian 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): S ystem set-up "Alarm history report Technician Name (print): Signature: / Certification No.: �i^'(1l US�� / License. No.: 3,40 15 t/ Testing Company Name: CHARLES E. THOMAS COMPANY Phone No.: ( 310 ) 323 6730 Address: 13701 So. Alma, Gardena, California 90249 Date of Testing/Servicing:/ Page l of 3