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- - .v• v �VJ,VVJY )J r u in rLuum tlAut bZ IvXONI7t RIN G SYSTEM CERTIROCATION For Use By All Jurisdictions Within tire State of California A errhority Cited: Chapter 6.7. Health and Sgjety Code: Chapter 16, Division 3, Title 23. California Code of Regulit&- This form must be used to doctunent testing and servicing of monitoring equipment. A separate certif(cation or revort must be prepared for each monitoring system Sontrol panel by the technician who performs the work. A copy of this Fitt p,_Wt �C prayi fc4 tq j tank sy-tem c,wncr/operator. The owner/operator must subunit a copy of this form to the local agency rr iulktW,v, j75� systems �- itt in 30 days of test date. A- GetteralInformation FacilityName•. S;&.g Site Address: t`z� Facility Contact Person: _ 1 Make/Model of Monitoring System: B. Inventory of Equipment Tested/Certified Tank ID: ll fGS.&I frnene ,O In -Tank Gauging Probe. A Annuls- Space or Vault Sensor. 13 Piping Sump/ Trench Sensor(s). .2 Fill Sump Sensor(s). O Mechanical Line Leak Detector. 0 Electronic Line Leak Detector. O Tank Overfill / High -Level Sensor. O Other (stecifv couiement tvm and Modc". Model: Model: LS Model: Model: Modcl: Tank ID: O In -Tank Gauging Probe. ti: O Annular Space or Vault Se Model: ❑ Piping Sump /Trenc nsor(s). Model: O Fill Sump Sc s). Model: O Mech inc Leak Detector. Model: DF tunic Line Lcak Detector. Model: ank overfill / High -Level Sensor. Model: 0 Other (specify cquioment type and model in_S_cction E on Page 2). Bid&, No.: City: Efil-elk C--,.".02 _ Zip: _ Contact Phone No.: (,IQ2 Date of Testing/Servicing: __2_/? 102- Tank ID: O in -Tank Gauging Probe- Model: 0 Algin ;lar Space or Vault Sensor. Modal.' 0 Piping Sump/ Trench Sensor(s). oriel: ❑ Fill Sump Sensor(s). Model: O Mechanical Line etcctor. Model: Cl Electronic Detector. Model: CI Tan Chill / High -Level Sensor. Modcl: Tank 10; ❑ In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: O Piping Sump / Trench Sensor(s). cl: O Fill Sump sensor(s). Model: 0 Mechanical line etcctor. Model: 0 Electronic ak Detector. Model: ❑ Tan erfilI J High -Level Sensor. Modcl: CI.FAer tweaifv eouionient tvoc and model in Section E on Paee Z). Dispenser 1D: Dispenser ID: O Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: O Shear Valvc(s). O Shear Valv0s). O Dispenser Containment Floats) and Chain(s). O Vis user Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). O Shear Valve(s). Dispenser ID: O Dispense C3Sh alvc ,If the facility contains more tanks or dispensers, copy this form. Dispenser ID: 0 Dispenser Containm=Oat(s) del: 0 Shear Valve(s). „ 0 Dis nserContainmain(i). Dispenser 1D: ❑ DisMs5ple6mairtmont Sensor(s). Model: O 5h alve(s). ❑ Dispenser Containi•lent Fioat{s) and Chain(s). formation for every tank and dispenser at the facility. C. Certification -I certify that the equipment identified in this document was inspectedJserviced 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 n Plot Plan showing the layout of tnotaltoriag equipment. For nay equipment capable of geoerating such reports, I have also attacbed a copy of the report; (Check all Alar a�+pty): O System set-up CI Ajbrm history report Technician Nairn (print): LA ��J s 1I d��S Signatwe: Certification No.: 3.:P 613 License. No.: Testing Company Name: s .Phone No.:( tog ) 464=81,3 ---._. Site Address: Date of Testing/Servicing: /_/ Page 1 or 3 03/01 Monitoring System Certification p C�a 1 Qs i� 2 �� ° So Ckr, �t� �Q - �1,� r/t% Q �