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09/19/2001 11:15 2094683433 FIFTH FLOOR PAGE 02 MO :6 NIT NG SYSTEM CE TIFICAG. ON For Use By 1411 Jurisdictions Within the StOle OfCalifornt4 Authority Cited- Chapter 6.7, fdealth and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations _-r__..__,. . rvt.mnctbeureoared This form must be used to document testing and stxvicing of monitoring equipment- A st ata for each pito ' s tem conrTol el by the technician who performs the work A copy tor must submit a copy of this form to tits local system owner/operator- The ownef/opera days of test date. A. General Information Facility Na=: City: % �� f7 �� % r Site Address: Contact Pbc Facility Contact Person: Hate Makc/Model of Monitoring System B. Inventory of Equipment Tested/Certified kc Cteeek thea ro r4air bozrs to indiexe s elfic i mentins cted✓srr�d: Tank 1D: �' a Tank ID: />> /r _F ' P In -Tank Gauging Probe 0 In -Tank Ciauging Pmbe.}4todel: d Annular Space or Vault ScnsOr. Model: Model: tl ✓� y3 _ cr' Annular Sparc ar Vault a Piping Sump i Trench 5 SPiping Sump / Trench Sensor(s)- Modell ❑pill Sump Sensor(s). 0 Fill Sump Scnsor(s). Model: �� ;' - Mechanical Line L,cak ] Line Leak Detector. 13 Electronic Line Leak D PMechanical Electronic Line Leak Detector- Model: ❑ Tank overfill /High -Lt odel: O Tank Overfill 1 High -Levet Sensor- Model- moe) in ? and model p Oter h c ui me ❑ Other nt Lank ID Tan)( iD: 5 C t ® in -Tank Gaugin; Probe. Model: 1l ya �J ' 3 Model- V r7 `r �o"� ❑ in -Tank Gauging ?rob, O Annular Space or Vaul 13 Annular Space or Vault Sensor. 0 Piping Sump I Trench Sensor(s). Model- Y `�� _ c I 0 Piping i tSump Se or($).h Q Fill Sump Sensor(s). Madel- _ _ Model: �J J/1 "� El Mechanical Line Lcak 8l Mechanical Line Leak Detector. a Electronic Line Leak E ❑ Electronic Linc Leak Detector. Model: ❑ Tank Overfill/ High -L O Tank Overfill / High -Level Scnsor. Model: model in Section E on Pae 2). ❑ Other if a ui ❑ Other s ecif a Lit cent t and -leDispenser i � ' 0 ID: Dispenser YD: 0 Dispenser Containment Sensor(s). Model: _ '��/ S ya ❑ Dispenser � Shear Valvee((s$).). lamer 13 tM Shear Valvc(s). ' a Dispenser Containment Flow(s) and Chain(s). 'R Di nscr Containma D- user 1D: r Dispenser ID: 3 *' p _ 3 DSL P� / D Dispenser Contain= ❑ Dispenser Containment ScnModel-. ❑ Shear Va)ve(s). W Shear Valvc(s)- nscrContainrncntFloat(s andClsaittsl. Q Di enscr Containtne pispenserID: � S enser 10: �) �� - y�I ISry 7 Model: 1 cJ y�,q O DispenserContaintne ispeoser Containment Sensor(s). � Shear Valve(s). ris hear Valvc(s). isoenscr Containment Float(s) and fitai s • Include tZ Di s eraser Contaimttc infotination.for every tank he facility contains more tames or dispensers, copy this form. C. Certification - I certify fiat the equipment identified in this document oras inspe�+�.+: ist gut rtif ic- Attached to this Certificatioa is fnformation (C -g. manufacturers' u �ttt correct and a Plot Plan showing the layout of monitoring egta¢ sument- set-up For anY 0 Alert attached a copv of the repo atpP�pJ� ®Sy Sigttatute: Technician Name (print): / License. No.. Certification No.: 1�7 Phc Testing Company Name: _ G Wit/ /ate, c Site Address: _!, 3 o a > a I Page I of 3 Monitoring System Certffleatioa this form must be proid to the tank lacy regulating L3S t 30. EC Bldg. No..__,__^� 1 PERMIT/SERVICES No.: tf Testing/ScMcing: Model: Wt. Model: VW, 7 A'? at(s)- Model: 21+5!7= Model. �- ctor. Model: T �1 /l _Ilk_ r2 tor. Model: Sensor. Model- 4,ut model in Section E on Pa^_e 2). Sensor. Model: ensor(s). Model: Model: )ctector. Model: xector. Model: vel Sensor-, Model: it type and model in Section E Sensor(s). Model: fit= Floatfs andel C- .ahain(s . )_,� /7/0 — v 1 _1311 Ccosortsl. Model: Float s) and Chain(s) Sensor(s). Model• loat(s) and Chain s) - dispenser at the facility. viced in sccoMancc with the manufacturers' necessary to verify that this information is ,pal)le of gene -tin: snob reports+ ! have also aistory report to ofT'esting/Seryicing : �/ 2 � l 03/01