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MONIT %xNG SYSTEM CERTIFIcO riON ` For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Cod eel io W This form must be used to document testing and servicing of monitoring equipment. A separate certificatio ort, must, be DreDared L/I IM for each monitoring system control panel by the technician who performs the work. A copy of this form musp,� vii�'tb tld rank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating f]° s st ms vZath n 30 days of test date. A. General Inf matio y�1 L Facility Name: (171 F&t-G. t 1 G(✓ '7 3 5�— Bldg. No.: Site Address: ( !T . 67 r-11 -kX- City: Tr6i c -/ Zip: -7 -� Facility Contact Person: _ `' c,=I r*j-i Contact Phone No.: z)61 83 3 -56 #- fie% Make/Model of Monitoring System: Maedi{ (roof 11� -35D ?),j6 Date of Testing/Servicing: _Zo/_jb/ 63 B. 'Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspect Tank ID: ''Y Tank ID: V ✓1, aL&G+ le" 1 C� In -Tank Gauging Probe. Model: 7 0-/07 In -Tank Gauging Probe. Model: 'f 7 V 0 -i �7 Amnular Space or Vault Sensor. Model: 4 0 °-4-4 241 �2r Annular Space or Vault Sensor. iviodei: 'c ` Gv " �d Piping Sump / Trench Sensor(s). Model: 0 c) •-. Lo ®' Piping Sump / Trench Sensor(s). Model: ®% o ' o Fill Sump Sensor(s). Model: 1�i3$6- 1p $ R'Fill Sump Sensor(s). Model: ® U ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (speciEy a ui ment a and model in Section E on Pae 2). ❑ Other (specify a ui ment e and model in Section E on Pa e 2). Tank ID: `.Z.,- Tank ID: In -Tank Gauging Probe. Model: �/ C - l f.�, ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. _ Model:cI 0 �- `(2 u ❑ Annular Space or Vault Sensor. Model: jd Piping Sump / Trench Sensor(s). lvlodel:6'1�3 270 " J ❑ Piping Sump / Trench Sensor(s). Mod Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). odel: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak D or. Model: 0 Electronic Line Leak Detector. Model: L C. _ iLietector. ❑ Elc�(specify Model: ❑ Tank Overfill / High -Level Sensor. Model: gh-Level Sensor. d�er Model: ❑ Other (specify equipment type and model in Section E on Page 2). ipment type and model in Section E on Pae 2). Dispenser ID: /12- Dispenser ID: 2zq ,❑ Dispenser Containment ensor(s). Model: C2'?1 0'a-0 $ Pr Dispenser Containment Sensor(s). Model: .3 80'20$ .O Shear Valve(s). _J k Shear Valve(s). ❑ DISDenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: 1T Dispenser Containment Sensor(s). Model: d `fib ?L El Dispenser Containment Sensor(s). Model: ,' Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s hain(. Dispenser ID: ❑ Dispenser Containment ❑ Shear Valve(sl_ Dispenser ED: -� ❑ Dispenser amment Sensor(s). Model: ❑ Sh alve(s). nment Float(s) and Chain(s). I J;Mispenser Containment Float(s) and "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 equipment capable of generating such reports, I have also attached a copy of the report; (check all that ap ly): System set-up ❑ Alarm history report Technician Name (mint): Z • W - C�-v✓LS Signature: c Certification No.: T-71 02 ®LI $ Ce License. No.: 0 Testing t,, .J[Mny Name: 1 I PL �"Q 1'e -M _5-�UCU S Phone No.:( 707 ) G %3 _ S Site Address: Date of Testing/Servicinz / y 46 Page 1 of 3 03/01 Monitoring'?tystem Certification