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Nll(L`NI -Al".-I `l3 rte? 'Ri M E'ER 11F_. ATI �� U ED ` Fur U.re tai'-all J111•i-W&WOM fl7thin the State t�f California .4whorih1 Cited:Chapter 6.7, Health and ScrfelV Code; Chapter 16, Division 3, Title,23, Calif brniu Cotle o/'Re,rularions /: 4 This form must be used to document testing and servicing of monitoring equipment. A separate ce Afi�c.1 ton or rep 8rt must be prepared for each monitoring system control panel by the technician who performs the work. A copyENVJ�&M p{�1#11, 1�yf�� ed to the tank system owner/operator. The-owner/operator must submit a copy of this form to the local agr rt11J�Ti �L �systems within 30 days of test date. A. General Information Facility Nr(i : Bldg.No.: Site Address: City: Zip: Facility Contact Person: % Contact Phone No.: Make/Model of Monitoring System: 'T" 3j� v Date of Testing/Servicing: S__// F iop B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific a ui ment inspect ed/sery iced: rp�(Mechanical k ID: OL S c ID: f "D n-Tank Gauging Probe. Model: /n��l% _ n-Tank Gauging Probe. Model: /jj/,1t1 J Annular Space or Vault Sensor. Model: /7it� ^c4nnular Space or Vault Sensor Model:Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ ill Sump Sensor(s). Model:Line Leak Detector. Model: 7Q V Mechanical Line Leak Detector. Model: Zw ppy ❑ 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 Page 2). 1 ❑ Other(s city equipment t and model in Section E on Page 2). T If ID: Tank ID: In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: a ❑ Annular Space or Vault Sensor. Model- Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:/46 24?o ir) ❑ 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 ci a ui ment a and model in Section E on Page 2). LJ Other(specify equipment type and model in Section E n, Pape?). Dispenser ID: �� Dispenser ID: �- ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Fd'Shear Valve(s). Dispenser Containment Float(s)and Chain(s). � Dis enser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: _�% N ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment.SSensor(sy Model: Shear Valve(s). 10 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). J3 Dispenser Containment Float(s)and Chain(s). Dispenser ID: C Dispenser ID: ❑ Dispenser Containment Sensor(s). el: ❑ Dispenser Containment S s Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floa(s) nd Chain(s). ❑ Dis enser Containment Floa and Chain(s). *If die facility contains moretanks or dispensers,copy this loan. Include information for every tank and ppdispenser at the facility. C. Certification - I certify that the equipment identified in this document was nsphcted/servi'cfed Pin coance 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;(cheek a//that apPw): ❑System se-up ❑ Alarm history report Technician Name(print): yj 12 1(t•n klp fr- Signature:_ Certification No.: 3 ys7� ILC 5v x'73-!1T nn �n -�^ License.No.: �•�L�- n$-/�3� Testing Company Name: /`1 }i- 2 r j�,A / S Phone No.:( Vq � 7y�. L►112- Site /ZSite Address: O Zr �� Date of Testing/Servicing: S / r 9/01 Monitoring System Certification i Page I of 3 03/01 D. Results of Testing/Servicing L__