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J ONITO NG SYSTEM CERTIFICAITION For UJW All Jurisdictions Within the State of Califor Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate cert' 'on or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of thivided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agencyyI g, within 30 days of test date. A. General Infor ation JUL 2 2004 Facility Name: 7"' No.: Site Address: 2001-ZAt1C1_50,n) ,4 tZ City: $L,4Z0 R/TISIpjDVIUQVII Zp Facility Contact Person: Contact Phone No.: (_� Make/Model of Monitoring System: 7_4 & 3sp Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/seryiced: Tank ID:' _ZJ. 0` 0"Tri-Tank Gauging Probc. Model: Tank ID: j�In-Tank Gauging Probe. Model:, -f& `Z. 2rAnnular Space or Vault Sensor. Model: f*, � e �- y Annular Space or Vault Sensor. Model: iping Sump / Trench Sensor(s). Model: .5!5,b ""Lea r- & Piping Sump / Trench Sensor(s). Modcl:_ > :> ,» y a T ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: Line Leak Detector. Model: u% i ❑�ptlechanical Line Leak Detector. Model: electronic Electronic Line Leak Detector. Model: tJ P it. % ank Overfill / High -Level Sensor. Model:1t>ep?`T'c) &L Tank Overfill / High -Level Sensor. Model: Ztvyf ; w 3v- ❑ Other (s ecif a ui mentty2c and model in Section E on Pae 2). ❑ Other s eci a ui ment a and model in Section E on Pae 2). Tank ID: Z f✓ 3 0 •Z_ Tank ID: Tank Gauging Probe. Model: _ 2ZSgZ2 ❑ In -Tank Gauging Probe. Model: ,Annular nnular Space or Vault Sensor. Model: --S ❑ Annular Space o Vault Sensor. Model- ��„�> (iping Sump /Trench Sensor(s). Model: sS ►� ,r�L`c i ❑ Piping Sump / , enc nsor(s). cl: ❑ Fill Sump Sensor(s). Model: ("Mechanical Line Leak Detector. Modell ❑ Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Det 1: ,J�Ae�e�zLt electronic Line Leak Detector. Model: ` AS i/ or. EI Electronic Line Leak De ctor. Model: Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecify equipment t c and model in Section E on Pae 2). ❑ Other (speci a ui mint tZpc and model in Section E on Page 2). Dispenser ID• A- -,4 Z_ Dispenser ID: A C3ispenscr Containment Sensor(s). Model:/U�¢❑ Dom' penser Containment Sensor(s). Model: W 14 "car Valve(s). ❑%S ar Valve(s). DIS enser Containment Floats and Chains . is enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valvc(s). ❑ Shcar Valve(s). ❑Dis enser Containment Floats and Chain(s). Cl 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. 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 t information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipm a e of neratin u reports, I have also attached a copy of the rep ch ck aQ� apply): *54ystcm set-up U�,Ala VK,h I ort Technician Name (print): �.j*��"G� Signature: Certification No.:—,, zy 9, License. No.: .1��y�� Testing Company Name;,47- Phone No.:(eOq b~7�f -4000 Site Address: Date of Testing/Servicing:.? /B?70V Page I of 3 03/01 Monitoring System Certification