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MONg"ORING SYSTEM CERT IV`'AT10�(� 2't /�Use/3y.1/l Jur i,rdiclions 1F71hin the Slule of Ca,., nia ( L n) lrrlhor ity Cited Chapter 6.7, Hen/lharadSafcry Code; Chapter•/G, Division 3, Tille 23, Ccrliforrara ode of e, urorasl This form must be used to document testing and servicing of monitoring equipment. A separate certif Art&6rgNG8111ust be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner%operator must submit a c y of this form to the local a R �L &Ufen,s within 30 days of test date. � PERMIT/SERVICESA. General Information 1 Facility Name: Site Address: teA4 ��v r Bldg.No.: City:_•.,,t L(G .1.2 Zip: r v Facility Contact Person: fes' le, Contact Phone No.:(_e 0 L ) (I&r. z ,li> Make/Model of Monitoring System: 'TU.S PD V) 2 Date of Testing/Servicing: .� 1j't7 /,p B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment In ected/serviced; Ta k ID: T k!D: n-Tank Gauging Probe. Model: L In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: H Z D Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Z o Fill Sump Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:_ /�^i. Mechanical-Line Leak Detector. Model: y.5"L D :-0 :.� ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tail:Overfill/High-Level Sensor. Model: ❑ Other(specify e ui ment type and model in Section E on Page 2). ❑ Other(specify_equipment t e and model in Section E on Page 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 ❑ Electronic Line Leak Detector. odel: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Senso . Model: Cl Other(s�ecify equipment type and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Di penserID: / - L KLIDispenser enser ID: - l ispenser Containment Sensor(s). Model: Z O ispenser Containment Sensor(s). Model - OShear Valve(s). hear Valve(s). Dis enser Containment Float(s)and Chain(s). Containment Float(s)and Chain(s). Dispenser ID: S" Dis nser ID: -�✓ Dispenser Containment Sensor(s). Model: 2 ispenser Containment Sensor(s). Model: ��r Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser Ill: _ Dispenser ID: ❑ Dispeliser 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 tante 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 fent. For any equilin nt capable of generating such reports,1 have also attached a copy of the report;(check alllhal app/t): System set- p / Alarm history report Technician Name(print): 3ignatu Certification No.: ';7 License.No.: ti ip '73-417-7-4!7- Testing Company Name: }►-or I :E5 7- Phone No.:( .�09 Site Address: Y yu el/ Date of Testing/Servicing: Page I ol•3 n3/ni,- {Nlonitoring System Certification