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MONRTIORING SYSTEM CERTH' PA7110N For Use By All Jurisdictions Within the State of California California Code 0 70'��du� "Y E DD Authority Cited.Chapter 6 7,Realth and Safety Code;Chapter 16,Division 3, Title 23, i This form must be used to document testing and servicing of monitoring equipment.A separate certification or report pMbe P-2 for each monitoring system control panel by the technician who performs the work- A copy of this form must be prove ea to the�03 system owr&r/operator. The owner/operator must submit a copy of this form to the local agency regulating US ffv"MTOHEALTH days of test date. PERMIT/SERVICES A. General Information Facility Nam: Bldg.No.: Site Address: 160 city: -,,40WtdR:,4 r-4, Zip: 9 5 33/6 Facility Contact Person: �44ZA,4 -S,4 le- Contact Phone No.: Make/Modelof Monitoring System: 62t(-6A42-<e,- �ltc<- Date of Tesd*Servicing: --et 6-3; B. Inventory of Equipment Tested/Certified Check the!RM2!tte brei to ludicate ad: T I& L Tank M, �tln-T Ganging Probe. Model: OA&—2- --- C�"1�-auk Gauging Probe- Modch ,ke4-C—=.-L- Annular Space or Vault Sensor. Model:az !10 it(3040 ular Space or Vault Sensor. Model: Crliping Sump/Trench Sensor(s). Model: 61-Mping Sump/Trench Sensor(s). Model: 0 Fill Sump sensor(s). Model: U Fill surrip-Sensor(s). Modek erIA'whauicai Line Leak Detector. model: 0.1&chanicat Line Leak Detector. Model: Cl Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: Q Tank Overfill I High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: 13 Others nt!M and model in Section E on Page 2). 0 Other(=a 2pk=t=and model in Section E on Page 2). TKID, 2— "U44 Tank ID: Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model- ular Space or Vault Sensor. Model: ;26-4/0 Cg?Q E3 Annular Space or Vault Sensor. Modeh ping Sump/Trench Sensor(s). Model- CL Q Piping Sump/Trench Sensor(s). Model: Q Fill Sump Sensor(s). Model: 0 Fill Sirrup Sensar(s). Modeh 2'9echankal Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Modeh L)Electronic Line Leak Detector. Model: 0 Electronic Line Le-*Detector. Modeh Ll Tank Overffl/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Modeh 0 Other(!E!2a==t=and model in Section E on PaQ Other Ls2=wif X 50!pMat!)r and model in Section E 2ELaE 2). Dispenser 11). Dispenser ID: 7—X (3 Dispenser Containment Sensor(s). Model: C3 Dispenser Containment Sensor(s). Model- gr§hear valve(s). ErShear Valve(s). nser Containment Pkiat(s)and Chain(s). >Dispenser Containment Float(s)and Chain(s). Dispenser l[D: --,%=!!i-- Dispenw ID.- L3 Dispenser Containment ensor(s). Model: 0 Dispenser Containment Sensor(s). Model: eSheaw Valve(s). Q Shear Valve(s). 211%s user Containment Float(s)and Chain(s). E3 Dispenser Containment Floats j and Chain(s). Dispenser,ID, 15-- ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: W9hear Valve(s). Q Shear Valve(s). inyonser Containment Floats)and Chain(s). 0 L)is 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 eevay not the eqidpneat idevried,in Ilds dommal was inspeetedhervieed in seeor&wee with the man"beturers* guidelines. Attached to this Certification is information (e g. manufacturers' checMists) necessary to verify that this information is correct and a Plot Plan showing the layout of equipment. For any eqt capable of generating such reports,I have also attached a copy of the report;(check all that apply): Mi set-up PA= h-istary repo A TechnicianName(print): e!!jA=v ItJ IrSignature: Certification No.: License.No.: Testing Company Name: Phone NoA g� — Site Address: X001Z--, i C4, Date of Testing/Sei-vicing: Page I of 3 03/01 Momtormg System Certification