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E T Dispatch . 6 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations Chis form must be used to document testing and servicing of monitoring equipment. A sena ate certification or report must be prepared for each nonitorinQ system control Panel by the technician who performs the work. A copv of his form must be provided to the tank system ownerioperator. Che owner/operator must submit a copy of this form to the local agency regulating LST systems within 30 days of test date. k. General lnfor ation acility Name: r—� Bldg. No.: lite Address: 32 2 N (' A i C City: fir tri�zip: P: �aeility Contact Person: t'� �%�( n C u Contact Phone No.: (_2ciclu vlake/Model of Monitoring System: VIA 1 L S -S s` 0 J Serial Number `t'G yS-7r 7 ZSG SQ 0 1 )ate of Testing/Servicing: 3. Inventory of Equipment 'Tested/Certified Q c1 �r Te sQj 3 2 3 S c ,sore s :heck the appropriate boxes to indirate ...Print , oa.., o„r «ea anklD:' j Fin 11aC�ar u. TankrD: -r2- p /n� ct' % ll (A S c ] In -Tank Gauging Probe_ Model _ � ❑ In -Tank Gauging Probe. Model: I Annuiar Space or Vault Sensor. r -Piping Sump /Trench Sensor(s). Modei: Model: .79 ❑Annular Space or Vault Sensor. Model: t'Fill Sump Sensor(s). y3uO -- 2 Model: G'�'Piping Sump /Trench Sensor(s). Model: _ 7 9 y� "1 C7 I Mechanical Line Leak Detector. 75 y360 - 2 2 3 Model:❑Mechanical 11 9 -Till Sump Sensor(s). Line Leak Detector. Model: 7f y,3(VC-- 32 ,; Model: I Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: I Tank Overfill ; HiQh-Level Sensor. Viodel.- li ❑ Tank Overfill / Hiah-Level Sensor. Model: 1 Other (sneciry equinmeat type and modei in Section E on 1,age 2,. ❑ Other s eci y e uipm nt _ ( q type aria ,, 2) i model in Section E or. Pa e _, ank ID: Z r eI Tank ED:I In -Tank Gaugmg Probe. Model- ❑ In -Tank Gauging Probe. Model: I Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: I -Piping Sump /Trench Sensor(s)_ Model: _7 7 yin O - 3z 3 ❑ Piping Sump / Trench Sensor(s). Model: I'Fill Sump Sensor(s), Model: 79 y 1&0 - 3 Z 1, ❑ 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: El Tank Overfill /High -Level Sensor. Mode]: Other (s ecify equipment ry e and model in Section E on Page 2). i ❑ Other (s ecifv_ equipment type and model in Stiction E on Page?) ispenser ID: Z Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 79 Y3 : -3 z 3 Dispenser Containment Sensor(s). Model 3 23 Shear Valve(s). ❑ Shear Valve(s). e Dis enser Containment Float(s) and Chain(s). i ❑ Dispenser Containment Float(s) and Chain(s). spenserID:S (a Dispenser ID: 7 ❑ Dispenser Contai mens Sensor(s). Model: 7 4 y 3cq0 - 2 z � Dispenser Containment Sensor(s). Model: 7 y Y3f?0 "-3 'Z3 Shear Valve(s). ❑ Shear Valve(s). Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). spenser 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). ❑ Dispenser Containment Float(s) and Chain(s). -the LaC41;t_ .-.�.,ro:..,.., ___ �.._ — _ __...., ,,,,., .,,, ...,,,,, -3 .,, Lubpu,isc,s, campy tnts corm. include mtormation for event tank and dispenser at the facility. 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 appiy): 1�-3ystena set -asp alarm history report chnician Name (print):/4A —� "° /� �n n o \ t ,, � Signature: rtification No.: 4 S Q i 7 License. No.: 302013 sting Company Name: CHARLES E. THOMAS COMPANY Phone No.: ( 330) 323 670-0 dress: 13701 So. Alma, Gardena, California 90249 Date of Testing/Servicing: 6v / l S / C -6 Page 1 of 3