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Page 1 of 3 03101 Monitoring System Certification MONITOWNG SYSTEM CERTMCATION , For Use By All Jurisdiclions Within the State of California n n Authority Cited Chapter 6.7., Health and Safety Cada, Chapter 16, Division 3, Title 23, Cal for 4o 1 q�(�1� v This form must be used to document testing and servicing of monitoring equipment. A se ate certification r re rt mus be reared for each monitoring system control ,panel by the technician who performs the work A copy of this form nMAye Urc&idU@4the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency reLatin UST systems within 30 hMONMENT days of test date. HEALTH A. General Information PERMIT/SERVICES Facility Name: i L '�i2`CLI�4 ACID Bldg. No.: Site Address: 9'7 VC -u 'pl,-(c y 13L.v'Ph ��t2 ,City: :4L� Zip:t Facility Contact Person: Contact Phone No.: (_^) Make/Model of Monitoring System: Q -14-IA(Z(-4 LSMC Date of Testing/Servicing: X- B. Inventory of Equipment Tested/Certified Check the apprapAate bow to Indicate gedfle !.a!!2Mm hispectediservited: Tank ID: ! - 53 7 T ID: (3�In_Tank Gauging Probe. Model:! Tank Ganging Prohe. Model: —_ Annular Space or Vault Sensor. Model: 10/1025l t 04-f lrAnmulw Space or Vault Sensor. Model: 00 9 P y 00Z iping Sump / Trench Sensor(s). Model: r°4 € 't Q errs G O'rPiping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(%). Model: 214echanical Line Leak Detector. Model: ILP Ve�.-j E1`14echanical Line Leak Detector. Model: _ ❑ Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: TT- D - _ a, i:4--ow ❑ Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfill / High-Level Sensor. Model: ❑ Other (sMifX equipment and model in Section E on Pae 2). ❑ Other (specify equipment tXE and model in Section E on Page 2). Tank ID: ` --7 Tank ID: Y- SAS � CY'ln-Tank Gauging Probe. Model: ,.A<.0-- �_ arin -Tank Gauging Probe. Model: re- - 2"Annular Space or Vault Sensor. Model:'4 -•t o 4 s / a Annuh:r Space or Vault Sensor. Model: alPiping Sump / Trench Sensor(s). Model: Pao A2e r; 0 t O Oliping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Stump Seasor(s). Model: 3**'Mechanical Line leak Detector. Model: LV,>I� fs ?Mechanical Line Leak Detector. Model: H i F'Z a- D Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill / High-bevel Sensor, Model: ❑ Tank Overfill / High-Level Sensor. Model• ❑ Other (specify ui anent qpE and model in Section E on Page 2). ❑ Outer (!egEl& 29i attent = and model in Section E on Pae 2). Dispenser ID: / - Dispenser ID: 77 -S i ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: WShear Valve(s). Cheaz Valve(s). j3, Dis user Containment Float(s) and Chain(s). CDis user Containment Float(s) and Chain(s). Dispenser ID: 3" Y Dispenser ID: 0- I Ir ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: a-9-hear Valve(s). E hear Valve(s), ids user Containment Float(s) and Chain(s. O'6ts nser Containment Float(s) and Chain(s). Dispenser. ID• 4;- -�- Dispenser ID-, ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Madel: tShear Valve(s). ❑ Shear Valve(s). ispenser 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 tank and dispenser at the facility. C. Cs cation -I certify that ibe egtupmeatt identified in this doenmeat w as inspeeteNseitvieed is aeeor-dimee with the atanufaeturen' 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 equa anent. For any equipment capable of generating such reports, i have also attached a copy of the report; (cheek all that apply): CSSyste n set-up C9� histo re , rt Technician Name (print): 4)L,u l Signature: � Certification No.: License. No.: J' O `(` �g Z o Testing Company Name: L° l ,a tit,'; �F� �iZ� �tsioi� 7'( IC Tl�t57"ra- & Phone No j Skgp�Address: 2 P <<-�— L 176,2, Date of Testing/Servicing: % t Page 1 of 3 03101 Monitoring System Certification