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<br />'
<br />IN, aON RING SYSTEM C:ER.TI ATION
<br />For Use By X111 Jurisdictions Within the State of Cal:{ania
<br />:1 uthorit. Cited: Char ter 6.7. Health and Safeq- Code; Chapter 16, Dil.:'sion 3, Tit'e 23• California Code of Regulations
<br />This form mast be used to document testing and servicing of monitorinc equipment..A separate certification or report must bP
<br />prepared fof each monitoring ;z% -stem control panel by the technician Nvho perfo.-ms the wo:k. A copy of this form must be provided to
<br />the tank systen? owner/operator. The ownerbperator must submit a coPy of this fl)rm t,- the lccal ao-n,• regulatir.E! LIST systPt„;
<br />\\ltrllii .J+J 61 ICJ! uatc.
<br />A. General Information
<br />Facility Dame: 6AG,I El L Bldg. No.:
<br />Site Address: 3i5 1 _� 64cu< &A rS Ci-.•: � f, 0', r, C', Zip:
<br />Facility Contact Person: Contact Phone No.: �)
<br />Make(Alodel of Monitoring System: _4_44 --Ag 46_n°il 1--01 Dare of Testing/Servicing: I z / 3 / G�
<br />B. Inventory of Equipment Tested/Certified
<br />Check the annronriate boxes to indicate snecific eouinment insnected/serviced:
<br />u Tank ID: t - Dr xEZ 2
<br />�al rt/Vil✓•✓ n) !�d' e, i `rr,L',il�
<br />Tank ID: _ S-7
<br />ii ❑ In -Tank Gauging Probe.
<br />Model:
<br />❑ In -Tank Gauging Prove.
<br />Model:
<br />II @' Annular Space or Vault Sensr..
<br />Model: LCL s - i
<br />CTArinuia- Space or Sensor.
<br />Model: CRL5 - I
<br />2 Piping Surr:o /Trench Sense- _ i.
<br />NIcdc;: ! -4-t s -
<br />0`5ipir.s c,,mn i Trent".
<br />Mode!: - .�Ai L c _ �
<br />Ipp ❑ Fill Sump Sensor(s).
<br />Model:
<br />ill Su -no Sensor(s).
<br />Aiodel: _
<br />tIl ❑'Mechanical Line Leak Detelto7.
<br />'Model: it, -oi-7/ m.-CIC;ld
<br />�,/
<br />1%Ieclha-ical Line Leak Detector.
<br />Model: I -01'7
<br />❑ Electronic Line Leak Detecto-.
<br />Model:
<br />❑ Elect; c»ic Line Leak Desector.
<br />Model:
<br />�I ❑ Tank Over: ll / High -Level Se--sor.
<br />Abdel:
<br />❑ Overfill / High -Level Sensor.
<br />Model:
<br />t%—,;!Tank
<br />1 ❑ Other (specify equipment t�and
<br />model in Section E on Page 2).
<br />O Other (soecifv e uioment rNe and
<br />model in Section E on Page 2).
<br />Tank ID: 2 - -D w -SSC. 2
<br />Tank ID: q - 7 -L
<br />N
<br />❑ In -Tank Gauging Probe.
<br />Abdel:
<br />❑ In -Tank Gauging Probe.
<br />Model:
<br />2Annular Space or Vault Sensor.
<br />,Abdel: La LS -t
<br />l`Annula- Space or Va_1: Sensor.
<br />;Model: 4-4,e 5,-
<br />a-Piping
<br />a-Piping Sump / Trench Sensorls).
<br />Model: L4. 5- t
<br />2`Viiping Sump / Trench Sensor(s).
<br />Model: e-,4es
<br />h❑ Fill Sump Sensor(s).
<br />Model:
<br />❑ Fill Sump Sensor(s).
<br />Modei:
<br />2`A•fechanical Line Leak Detec,o-.
<br />❑ Electronic Line Leak Detector.
<br />Model: ti_ _it
<br />Model:
<br />2_NQechanj:al Line Lea; Detector.
<br />❑ Elect -,o Line Leak Detector.
<br />Model:
<br />-:c
<br />Model:
<br />fl O Tank Overt -ill ; High -Level Sensor.
<br />Model:
<br />❑ Tank Overfill / High -Level Sensor.
<br />Model:
<br />❑ Other (specify equipment type and model in Section E on Page 2).
<br />U ❑ Other (s�ecifv equipment type and model in Section E on Page 2).
<br />Dispenser ID: t - t Z
<br />Dispenser ID:
<br />IiI❑ Dispenser Containment Sensorfs).
<br />,_.,/
<br />'J Shear Valve(s).
<br />Model:,
<br />❑ Dispenser Containmen: Sensor(s).
<br />❑Shear Va!ve(s).
<br />Model:
<br />!I ❑ Dispenser Containment Floatis) and Chain(s).
<br />❑ Dispenser Containmen; Float(s) and Chain(s). e
<br />Dispenser iD:
<br />Dispenser ID:
<br />❑ Dispenser Containment Senso-i's).
<br />Model:
<br />❑ Dispense- Containmen: Sensor(s).
<br />Model:
<br />❑ Shear Valve(s).
<br />❑ Shear Va]ve(s).
<br />n r!:en,nv-r Cnntainment Flna-(cl nn. -_i
<br />Fl^2t(S1 4
<br />'
<br />II� Dispenser ID:
<br />Dispenser ID:
<br />li ❑ Dispenser Containment Sensor(s).
<br />Model:
<br />❑ Dispenser Containmen: Sensor(s).
<br />Model
<br />k ❑ Shear Valve(s).
<br />❑ Shear Valve(s).
<br />I ❑Dispenser Containment Float(s) and Chain(s).
<br />❑ Dispense- Containmen: Float(s) and Chain(s).
<br />'If the facility contains more tanks or dispensers, copy this fo m. Include information for every tank a, -.d dispenser at the facility.
<br />C. Certification - 1 certify that the equipment identified in this document was inspected/serviced in accordance with the
<br />manufacturers' guidelines. .-attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this
<br />information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such
<br />reports, 1 have also attached a copy of the report: (check all rhar apply): D System set-up ❑ ta
<br />rrp ist. ` report
<br />Technician Name (print): /��,j , o L, A 14,/3 a ,Z13 Signature: ���
<br />Certification No.: License. No.:
<br />f� ^_ C 0»? \pme'
<br />�al rt/Vil✓•✓ n) !�d' e, i `rr,L',il�
<br />T.'z�r ni,,C, ",
<br />Site Address: 55 ( ,(J.
<br />B,!F-,tA, e'er 4-6 Qi C',q;
<br />DareofTesting:Servicing:
<br />:Monitoring Sx•stenl Certification
<br />D. Results of Testing/Servicing
<br />Page 1 of 3 03/01
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