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ONI RING SYSTEM CE TIN TIOI®1 I i FP Ilse 4v,4//Jurisdictions Within the State of Californ�a 00,7 Authority Cited: Chapter 6.7, Health and Sgfety Code; Chapter 16, Division 3, Title 23, California Code 67 u`krAll This form � j: must be used to document testing and servicing of monitoring equipment. A separate certificat t f4gb'`4-W' prepared for each monitoring system control panel by the technician who performs the work. A copy of this &Irn t: �`° ` to the tanks stem owner/operator.erator. The owner/operator erator must submit a co U'ST Y p p �y of-this form to the local agency regulating systems within 30 days of test date. A. General Information t / Facility Name: . // Bldg.No.: Site Address: �p 33 G . V 1 C-70 O— City: 4-oD/ Zip: Facility Contact Person: 81 w Contact Phone No.:(�_) 54-1-1 --) Make/Model of Monitoring System: 06000 ROO—r "7?--S— ZS® Date of Testing/Servicing: 2/ !5/01— B. Inventory of Equipment Tested/Certified Check the a0propriate boxes to indicates chic equipment ins acted/serviced: Tank ID: sx Ta9k 1D: �„—/- �-Tank Gauging Probe. Model: Tank Gauging Probe. Model: d Gi nnular Space or Vault Sensor. Model: I! Z pular Space or Vault Sensor. Model: F Piping Sump/Trench Sensor(s). Model: 1 G Piping Sump/Trench Sensor(s). Model: O�j ❑ M1 Sump Sensor(s). Model: UVHI Sump Sensor(s). Model: Jff Mechanical Line Leak Detector. Model: Z Mechanical Line Leak Detector. Model: 9RL.A Zoota ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: vr"tchanical her(specify equipment t e and model in Section E on Page 2). ❑ Other(specify a ui ment ty a and model in Section E on Pae 2). Ta ID: Qe--r Tank ID: Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: DV ❑ Annular Space or Vault Sensor. Model: ing Sump/Trench Sensor(s). Model: rj ❑ Piping Sump/Trench Sensor(s). Model: Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Line Leak Detector. Model: FX- I V ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model- ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: w ❑ Other(seecify a ui ment!Xpe and model in Section E on Pa a 2). ❑ Other(s eci a ui ment t e and model in Section E on Page 2). �Dis enser ID: 1 "t- �— Dis genser ID: T-f- g ispenser Containment Sensor(s). Model: $�AtwO¢aErp c 40 G� .8'Uispenser Containment Sensor(s). Model: i{p 6 Shear Valve(s). r Valve(s). ODis enser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dis enser ID: 3 el-`f Dispenser 1D: ispenser Containment Sensor(s). Model: q0(o ❑ Dispenser Contaimnent Sensor(s). Model: .�$Iiear Valve(s). ❑ Shear Valve(s). Fd Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). D��Di PPPenser ID: T Dispenser ID: �spenser Containment Sensor(s). Model: ��(o ❑ Dispenser Containment Sensor(s). Model: ��hear Valve(s). ❑ Shear Valve(s). 4dDis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)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 equi lent. For,any equf went capable of generating such reports,I have also attached a copy o!trye report;(check all that apply): System set-u Alarm history report Technician Name(print): &kf— /YtMM p Signator : Certification No.: //03 License.No.: Testing Company Name: P,477 Phone No j9 z ) �� A; Site Address: 6130 /6 6 Date of Testing/Servicing: . � Monitoring System Certification Page 1 of 3 03/01 D. Results of Testing/Servicing