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MONOOMG SYSTEM CERTIF*TION 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 This form must be used to document testing and servicing of monitoring equipment. A se arate certificationJ \i I for each monitoring_ system control panel by the technician who performs the work. A copy of this form fi tank' system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating tJST systems within 30 days of test date. J U L 2 4 2002 A. General info n Facility Name: L .� ERo�CCE L�tve S NT NEINTH Site Address: CfUCJ S City: f— t Kj?tMIT/S Facility Contact Person: OqA /Iib f/i4 LJ4 Contact Phone No.: ( 0 T — 9-5V Make/Model of Monitoring System:/ l� ec- pi(_ Date of Testing/Sirvicing: 7 /ZY/6 7— B. B. Inventory of Equipment Tested/Certified Check the atmroariate boxes to Indicate specific equipment Inspected/serviced: Tank ID: (7 Tank ID: Z All h ❑ Tank Gauging Probe. M l: 13"n -Tank Gauging Probe. Model: FlAnnular Space or Vault Sensor. Model: ,�q%/ YOW ular Space or Vault Sensor. TV"l: %�U LSY//y�1Ddo Piping Sump / Trench Sensor(s). Model: L�<7l]?S`f �d 4�� t3 Piping Sump / Trench Sensor(s). M{nde1: 1?D7 rV.2tWo< ❑ ill Sump Sensor(s). Model: ❑ fill Sump Sensor(s). el: Mechanical Line Leak Detector. Model: j 1 h — 05-6 O Mechanical Line Leak Detector. 1: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. 1: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. el: ❑ Other (specig equipment t and model in Section E on Page 2). 0 Other (speciequipment type and 1 in Section E on Page 2). Tank ID: f 'cc Nc r Tank ID: ct_' ' v ❑ Ip -Tank Gauging Probe. Model: LJ Gauging Probe. el: Annular Space or Vault Sensor. t� Piping Sump / Trench Sensor(s). Model: P/7 15 �[1�'iad0 Model: 02 C�j ZODG 000 pular Space or Vault Sensor. Piping Sump / Trench Sensor(s). 1: P-ar[ ,ZS 4 011(doa �=I: 4qoLS ( L3 Fjril Sump Sensor(s). Model: ❑ f ill Sump Sensor(s). Model: aYMechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: //,6 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: O Tank Overfill / High -Level Sensor. Model: ❑ Other (specify ui ment type and model in Section E on Page 2). ❑ Other (specify equipment t and 2ael in Section E on Pa 2). Dispenser ID: Dispenser M. ❑ Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). U Dispenser Containment Floats and Chain(s). Ll Dispenser Containment Float(s) and ain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). oriel: ❑ Shear Vaive(s). 0 Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). 0 Dispenser Containment Float(s) and ain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). oriel: ❑ Shear Valve(s). ❑ Shear Valve(s). UDispcnser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and ain(s). 'If the facility contains more tanks or dispensers, copy this form Include information for every tank and dispenser at facility. C. Certification - I eer4ify that the equipment identified in this document was inspected/semiced in seeor4anee 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 generiating such reports, I have also attached a copy or the rep ( heck oil apply): ❑ System set-up 0 A sto'"► � _ Technician Name (print): n 3%_0.1'"K S Signature: -��t�( .�-- Certification No.: 3 L Lic cense. No.: Testing Company Name: ��PlON 7-4 tyk Te--_j-7;7i4 9 Phone No.:( 5-06 ) 6 60 ` gyY3 3o S'9 X r Site Address: �� U On 3U Sri S� �i Cf4 9.S �l �— Date of Testing/Servicing: 7 System Certification Page 1 of 3 T�j ('-0 tA os4� MC. rQsvlf3. 0"I