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MONITORING SYSTEM CERTIFAl"ATION Use 41'.41/Jill-isc/ictions 11711tin the.State of Cn Ilia .4uthority Cited.- Chapter 6.7, anel Snfeh�Cocle; Chapter/6, Division 3, Tille 23, California Code of Regtrlalioczs This form must be used to document testing and servicing of monitoring equipment. A separate certification or re ort must be prepared for each monitoring system control panel by the technician who performs the work. A c sff p vided to the tank system owner/operator. The.owner/operator must submit.a copy of this form to the Mit s stems within 30 days of test date.-- � -----�- __ __ y A. General Informationff NOV A 4 2008 CLj Facility Name: n We if ISD( vl e f Bld,g.No Site Address: qt�o S. Ch -Pry e¢'d er hF City:��c e �ENV� N�} Facility Contact Person: A5''1i_1 . -e fSE W Contact Phone No.:( ) 33 '7r-- Make/Model of Monitoring System: ` a � } Date of Testing/Servicing: /oaf D� B. Inventory of Equipment Tested/Certified Check the a i ro riate boxes to indicates ecine a ui ment ins ected/serviced: Tank ID: 7 Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: I�1{'nnular Space or Vault Sensor. Model: --1'}6 ❑ Annular Space or Vault Sensor. Model: Ljz- Ct�-t�ping Sump/Trench Sensor(s). Model: -7-01 ❑ 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: ❑ 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 ty a and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Tank ID: 91 Tank ID: D./B 5 'e I ❑ In-Tani:Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: U-11ping Sump/Trench Sensor(s). Model: ©E" ❑ Piping Sump/Trench Sensor(s). Model: p u ►Fill Nump sensor(s). Model: ❑ 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(specify equipment type and model in Section E on Page 2). ❑ Other(specify a ui ment tv a and model in Section E on Pa e 2). Dispenser ID: �-�-- Dispenser ID: �j � `f ❑ Dispenser Contaimnent Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). C� Dispenser Containment Float(s)and Chain(s). ':' ;3�Dispenser Containment Float(s)and Chain(s). Dispenser ID: e1'- t/O Dispenser ID: LIDispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). is enser Containment Float(s)and Chain(s). Dis enser Containment Float(s)and Chain(s). Dispenser ID: !0 Dispenser ID: C3 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). is enser Containment Floats)and Chain(s). Dis enser Containment Float(s)and Chain(s). ''ITthe 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 Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attach d a copy of the report;(check all that apply): ❑Sy em pe�r��'Ala�rm history. ort Technician Name(print): D. ��/,'mmn Signature: ��s!iOV_ Certification No.: /ons License.No.: 9() --/f Testing Company Name: 7A Phone No.:( Dg 'N4Site Address:Address: Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification D. Results of Testing/Sel•vicing �C