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NNGYST C T ATS CC � �I.� EDD (Ise By , tU Jurisdictions 14,71hin the State of C'a carnia l nthorily C'itecl: C'haj.?Ier 6.7, f earth ancf .Safefi Code; Chapter 16, Dig inion 3, Title 23, California Y a� c Ir�{{��yy qft 9ns This form must be used to document testing and servicing of monitoring equipment. Ase crate certification r&i�e St PH. for each monitoring system control panel by the technician who performs the work. A copy 1the tank system owner/operator. _ The owner/operator must submit a copy of this form to the local aged)' stems within 30 clays of test clate�` �i > A. General Information Facility Name: 11,911, /Vido Bldg, �'r No.: Site Address: s'f�c/ /�%�J,�»//""City: ,C �Zip: Facility Contact Person: LA,,) Contact Phone No.: ( ) Make/Model of Monitoring System: V/0. jos Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snecific enninment incnorto,voo ,: d. T nk ID: 0c In -Tank Gauging Probe, Model: Tank ID:f>Se.- AMW a Panular Space or Vault Sensor. Model: In -Tank Gauging Probe. Model:. %�•- _ , Annular Space or Vault Sensor. Model: — iping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). TL.CJ Piping Sump / Trench Sensor(s). Model: �U' Model: Mechanical Line Leak Detector. Model: L ❑ Electronic ❑ Fill Sump Sensor(s). Model: _ Mechanical Line Leak Detector. Model:' Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: ❑ Other (s ecify e ui ment type and model in Section E on Pa a 2). ❑ Tvilc Overfill / High -Level Sensor. Model: ❑ Other (s ecify equipment ty a and model in Section E Pa T. nk ID: ° t on a Z). Tank ID: nkTank In -Tank Gauging Probe. Model: %%ji�(i / ❑,_,�r Annular Space or Vault Sensor. Model: ❑ Gauging Probe. Model: ,Ia Piping Sump / Trench Sensor(s). Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:Vh�� ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Electronic Line Leak Detector. Model: Line Leak Detector. Model: ❑ Electronic Line Leak Detector. ank Overfill / High -Level Sensor. Model: ther (specify equipment ty a and model in Section E on Page 2). Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify !21 i meat t e and model in Section E on LDispenser ID: Z_ a. ispenser Containment Sensor(s).Model: Dispenser ID: 7 ❑ hear Valve(s)' ispenser Containment Sensor(s). Model: 'hear is censer Containment Float(s) and Chain(s). Valve(s). nser Containment Floats) and Chain(s). DispeDispenser Dispenser ID: �-- y ID: ❑ Dispenser Containment Sensor(s). 'Model: ❑ Dispenser Containment Sei or Model: hear Valve(s). ❑ Shear Valve(s). Dis enser Containment Floats) and Chain(s). ❑Dis enser Containment F at(s) id Chain(s). Dispenser ID: � Dispenser 1D: ispenser Containment Sensor(s). Model: Shear Valve(s)' L3 Dispenser Containment Sen r(s). Model: g❑ Dis enser Containment Float(s) and Chain(s). ❑Shear Valve(s). ❑Dis Dispense 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 equipment. For any equ�ipqsent capable of generating such reports, I have also attached a copy of the report; (check all that app&): S stem set -u Technician Name (print): y Alartrt history report (p ) AVi�,� lC% �,�1 t•st r,®" Signator : i Certification No.: XV75L° 'F 52 ✓73-41r License. No.: ` j!j7r /) Testing Company Name: / m0 r z A 5,7 Phone No.:( Zt r %'��%, 41//Z Site Address.- 3��t/ �,? /.'YJ�JtA� G,f Date of Testing/Servicing: /27/ 0J- Monitoringn Systeaq, Certification s Pare I ol'3 _ 03/01 D. .Resiiuks ttt° E e4,,t su�A / yeu'c acil��;