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MONY IRI NG SYSTEM C E RTIFIC 1T'ION P _Ls•e By.1//Jurisdictions 1pithm the S'I(Ile(?f Ca/il, a .1 rrthority Cited: Cllclpter 6.7. Alealth and Sgfcty Code; Chapter 16, Division 3, Tit%23, CMCI, L n s This form must be used to document testing and servicing of monitoring equipment. A sea on Io�r re ort must be prepared for each monitoring system control panel by the technician who performs the work. A copy o this fort�, }� eprovided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local ii .submit systems within 30 clays of test date. �� A. General Information ENVIRONMENT HEALTH Facility Name: _ //fJ)*J (�^- PERN�T�S�VMS b Q.: Site Address: / � �" �. "�'' /✓ t City:__rt' q s-.EC"t .�+ Zip: S-�U Facility Contact Person: (i` Contact Phone No.:( t ,�r ) cf "P, Make/Model of Monitoring System:'TW 310 t1 2 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro rinte hoses to indicate specific a uipmeot ins ected/serviced: Ta k ID: T, k ID: Tn-Tank Gauging Probe. Model: fya9 L In-Tank Gauging Probe. Model: z. Annular Space or Vault Sensor. Model: `(Z c7 Annular Space or Vault Sensor. Model: r >. / Piping Sump/Trench Sensor(s). Model: Xodl Piping Sump/Trench Sensor(s). Model: ,n gr Fill Sump Sensor(s). Model: 13Fill Sump Sensor(s). Model: ,1j Mechanical Line Leak Detector. Model: n"t dMechanical•Line Leak Detector. Model: A77_,_• DUu ❑ 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). Ll Other(s ecify equipment t e and model in Section E on PaLe 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Mode ❑ Annular Space or Vault Sensor. M del: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Mo el: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Mod ❑ Mechanical Line Leak Detector. Model- ❑ Mechanical Line Leak Detector. el: " ❑ Electronic Line Leak Detector. Mod E3 Electronic Cine Leak Detector. odel: ' ❑ Tasilc Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Senso. Model: ❑ Other(s Pecify equipment type and model in Section E on Page 2). ❑ Other(s eci equipment t e and model in Section E on Pa a 2). D� penser 1D: ;PDispenser ' penser ID:_ „f y ,( ispenser Containment Sensor(s). Model: Z U Containment Sensor(s). Model: Z O/ l?Shear Valve(s). Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: S" PSI nser ID: Dispenser Containment Sensor(s). Model: 2 V ispenser Containment Sensor(s). Model:Shear Valve(s). ear Valve(s). ❑ Dis.enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 777 Dispenser ID: L3Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser 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. 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 equip ent. For any equipn nt capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set- p Alarm history report Technician Name(print): Si nate klP.�- g / Certification No.: 417 2 License.No.: ti —L Jt-- n Testing Company Name: ter: A F'S 7' Phone No.:�-2)_ 7�/�/. 6 Site Address: yl� I _ �1,A/ {� Date of Testing/Servicing: Monitoring System Ccrti6'ic:otion Page 1 of 3 03pw IT. Rcsuhls o$"f e- inn/S rvici )g