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MONITORING SYSTEM CERTI1 _11AT10 Use 41,.4/1 Jurisdictions II.7t/jin 1/7e Stu/e of Ccnrlornia .4whority Ciled: Chapler 6:7, Hecilth and Snfeo,Code; Chapter 16, Division 3, Title 23, Californ This form must be used to document testing and servicing of monitoring g g equipment. A separate certification or re or' must bh•• a prepared for each monitoring system control panel by the technician who performs the work. A copy of this form �j.� b rovided to the tank system owner/operator. The-owner/operator must submit a copy of this form to the local agency reglti til 1 57 � ms within 30 days of test d�6. �z A. General Information SAN JOAQUIN, FacilityName: 044A W, ).y+6W i2.' r ai► ENVIRONME y ,-n B Id�-l�7-�QEF, Site Address: Zliv i? Ci ty: S�-/J�•i'�f-Jn Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: Tt!C 3Sl) Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a n o riate boxes to indicate specific equipment inspected/sen-iced: T rnI ID: T nk ID: L In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: Z ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: X Fill Sump Sensor(s). Model: Z(� Mechanical Line Leak Detector. Model:��" -/jr,L(/) Mechanical'Line Leak Detector. Model: ^. 1"yO— ❑ 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 Pa a 2). ❑ Other(speciLy equipment[ e and model in Section E on Page 2). ,T nk ID: G Tank ID: In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. odel: �❑.Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. odel: j ,'iping Sump/Trench Sensor(s). Model: 2 D.V ❑ Piping Sump/Trench Sensor(s). M d 7'Fill Sump Sensor(s). Model: _ ❑ Fill Sump Sensor(s). M I: Mechanical Line Leak Detector. Model:s, - ❑ Mechanical Line Leak Detector. od : ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model. ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s)ecify equi ment type and model in Section E on Pace 2). ❑ Other(s eci a ui ment type and model in Section E on Pa'e 2). FDiseenser enser ID: 1' Di enser ID: ispenser Containment Sensor(s). Model ispenser Containment Sensor(s). Model: hear Valve(s). Shear Valve(s). Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Di enser ID: s- Y Di, enser ID: 11 ispenser Containment 5ensor(s). Model: - ZO& Dispenser Containment Sensor(s). Model: 7r Shear Valve(s)' Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Conti�inmentensor(s). odel: ❑ Dispenser Containment Sensor( oriel: ❑ Shear Valv ❑ Shear ser C n❑Dis enser Coat(s and ain(s). ❑ Dispenser Containment F at(s)a Chain(s). 11f the 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 equi ent capable of generating such reports,I have also attached a copy of the report;(check till that applp): X-1 yste set-up Alarm history report Technician Name(print):��Vr i7 a , g Signatur Certification No.: 3yS)f" , t'e- License.No.: �•�L �n�-�'�� Testing Company Name: cyC b A 7g-5 r Phone No.:� i0q 'y�//,Z Site Address: �fd'� /. / p� Date of Testing/Servicing: /Z7/fly Monitoring System Certification Page 1 of3 113/111 9. Results cif Testslrn/Servichzg