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N YST C� T ATION r i Lrse Bn.4HJuriscictions Gb7lhin the State gf�Ccr r ornin �C � 7 �) �;k�� Authorily ('ilecl: Chapter 6.7, Health and SgMj) Code; Clrcrpter 16, Division 3, Tille 23, C'alifornicr C'ocle of 2cgilh-t' ons This form must be used to document testing and servicing of monitoring equipment. A separate certificati �br Ye( it�YMt be prepared for each monitoring system control panel by the technician who performs the work. A copy of thi� rI Inti t. Qy _ the tank system owner/operator. The owner/operator nnist submit a co of this form to the local aRenc within 30 days of test dais`' copy b �'';>I „� '�'tn" A. General Information Facility Name: �a�i'I.t il�tf��' �.��t oil 11A1 e Bldg. No.: Site Address: -?30e/ �1�y,�shrr �� City: _.s•�C �� Zip: Facility Contact Person: 2�',6,J Contact Phone No.: ( ) Make/Model of Monitoring System: Date of Testing/Servicing: a // B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to indicate s ecific a ui ment ins ected/services T nit ID: In -Tank Gauging Probe. Model: nnular Space or Vault Sensor. Model: l iping Sump / Trench Sensor(s). Model: 7— LJ Fill Sump Sensor(s). Model• Mechanical Line Leal: Detector. Model: .�J' /�- j Ijo ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specifye ui ment type and model in Section E on Page 2). T nk ID: t In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ,Piping Sump / Trench Sensor(s). Model: —� ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model ❑ Electronic Line Leak Detector. Model ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Dispenser ID: 1-2— d❑ ispenser Containment Sensor(s). Model: ear Valve(s). , Dispenser Containment Float(s) and Chain(s). Dispenser ID: �— y ❑ Dispenser Containment Sensor(s). 'Model: hear Valve(s). yff Dis enser Containment Float(s) and Chain(s). Dispenser ID: �^ ispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Float(s) and Chain(s)- Tank ID: AMW '12r e— In -Tank Gauging Probe. Model:_ �/ Annular Space or Vault Sensor. Model: YI-0 Piping Sump / Trench Sensor(s). Model: ZOE ❑ Fill Sump Sensor(s). Model; _ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment t e and model in Section E on Page 2). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: LJMechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci a ui ment t e and model in Section E on Page 2). Dispenser ID: ❑ j)ispenser Containment Sensor(s). Model: ,W" hear Valve(s). Dis enser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment SXorModel: ❑ Shear Valve(s).❑Dis enser Containment Fd Chain(s). Dispenser ID: ❑ Dispenser Containment Sen r(s). Model: ❑ Shear Valve(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 verity that this information is correct and a Plot Plan showing the layout of monitoring a mp ent. For ,my equip ent capable of generating such reports, I have also attached a copy of the report; (check all that appy): System set-te Alarm history report Technician Name (print): Ayf ��},'� k%,o �� Signature: I, Certification No.:tf,��f —./- P7 r`� �'y 3'l!T License. No.: �-�^�„ ik• � �— � % Testing Company Name:/ y i�A 7- Phone No j 2(.) > 71/4, 6//Z Site Address:3G' y Date of Testing/Servicing:. Monitoring I';agc 1 of3 03/111 n System Certification , P.h