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E T Dispatch MONITORING G SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited. Chapter 6.7 Health and Safe(}Code; Chapter 16, Division 3. Title 23, California Code ofRegulations Chis form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be orenared for each nonitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. Che owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. k. General Information _ acility Name: D"� c l Bldg.No.: Site Address:!C 1 '^- r -' U 11�i`�h t t City: !�i �C\-�(_(�i Zip: Gl t? acility Contact Person: (1 Contact Phone No.:(� -7 y (e -60`o vlake/Model of Monitoring System: `//(( Serial Number 7(; y,Z 7 Z Z v C C) Date of Testing/Servicing: G G )) •-s1'zt / S B. Inventory of Equipment'Tested/Certified Os1y Z heck the appropriate boxes to indicatespecific a ui ment inspected/serviced: rank ID: '7- Tank ID: 1 Z In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: :3 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 'Piping Sump/Trench Sensor(s). Model: ) `r Y.Z"t_ 3 2 a?iping Sump/Trench Sensor(s). Model: -7`i Y 3 r;('_ -3 L >. 3-Fill Sump Sensor(s). Model: '7 V'/3<1�C' - M-Fill Sump Sensor(s). Model: ZI Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: J Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: D Other(specify equipment type and modei in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). I rank ID: -7-,_� Tank Ill: :1 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: -1 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: D'Piping Sump/Trench Sensor(s). Model: '7 3 2 > ❑ Piping Sump/Trench Sensor(s). Model: 11-Fill Sump Sensor(s). Model: 7 2-7 s ❑ Fill Sump Sensor(s). Model: J Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: :1 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 3 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: :1 Other(specify equipment e and model in Section E on Page 2). ❑ Other(specify e ui merit type and model in Section E on Page 2). Dispenser ID: r/Z Dispenser ID: 3 3 Dispenser Containment Sensor(s). Model: 7 1 Y_3 R C --:3 2 ❑ 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). Dispenser ID: SSC Dispenser ID: 7 t� 7 Dispenser Containment Sensor(s). Model: 7;y`2 Ei C'-Z2 .t ❑ Dispenser Containment Sensor(s). Model: '—( 7 Y3 t'C 7,22 J Shear Vaive(s). ❑ Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Aspenser ID: S//C Dispenser ID: 't, L :3 Dispenser Containment Sensor(s), Model: 7 9 Y 3:'C -',- ? ❑ Dispenser Containment Sensor(s). Model: :1 Shear Valve(s). ❑ Shear Valve(s). 3Dispenser 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. Z. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' Quidelines. 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 capabie of generating such reports,I have also attached a copy of the report;(check all that appiy): aSystem set-asp Alarm history report Fechnician Name(print): Signature: - -- J :ertification No.: 4 t 1 i ? License.No.: 302015 Cesting Company Name: CHARLES E. THOMAS COMPANY Phone No.: ( 310 323 6730 address: 13701 So. Alma, Gardena, California 90249 Date of'1'esting/Servicing: ; Page l of 3