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MONITORING SYSTEM'CERTIFICA"I" .fulhority C11rd'. Chap NeU%h [! �) .411,!11+•lsdiCtior)tt ttrrlhinibe.%j,. fC.�a/ carnia IQN Chapter 6, ndl SOO Code- (Ita�ter l h, 1?rwisfon 3, Til1e 23, Caliifo l.nia Code v R f 1�tiK I�Orrn n71t.Ct he tI5LXl t(t tltlCllnlCn[ Ivtiiln ./• NA'rrtativns ( 1_ltt3t it rilla S-L•S(CIt1 L I Et and servicing or monitoring equipment. n urnto "I'liiie+tigil r r •� muxt_ »�� ouch ►(�lLQ ,( tt. tEte tLChniciun who perlitrtns the work. A copy of Nis form must be proc•idcd to the lank s7,stem owner/0 rater. I'hcoLLnerkptcttltor must submit a cop)• of lhis (ilial to (hc IOL -di tlgcnG) regulating 11S'I'systtnts within 3� days of test data A. General Information Facility Name' _ f1�' Site Address: _ Bldg. No.: -- City: Zi Facility Contact petull: Contact Phone No.: ?-, o Make/Model of Monitoring Sys(etrt; _ `! 3 b mate of'resting/Servicing: D. Inventory of Equipment Tested/Certified A:. � k: n a,.r n . f"rl al -Inge ®anti to IndicaIc $ 1tIC C Ill InCflt Inx eCtCd/34rYii [Annular Space or Vault Sensor. Tank ID- D: (7ipingSump /-Troneh Sensor(s). ,,:': Ilk rank Gauging Pnibe. Model: �Mechanical Linc Leak Detector, Afloulin Space or Vault Sensor, t!l"Pining Sump/Trench Sensoris). ML]de1:�t— Model: d Fidl %utnp Sunstlrts)• (L9alel: M !del: Q Other (SNCl6' cquipmen( type and model in Seeuttn ? o c 2). i�Mechanical Line Leak Detector. Model: © In -Tank Gauging Probe. Q Llewronic Line Leak Ntector. t: Model: Model: tank (hcrlill i lligh-Level Sensor. 4ludei: ® Fill Suntp Sensor(s). O(hCrispecitj cqu(pmtau tine angl n7uJel in Q MCtdtanical Line leak Detcclor. Tank ID:la-Tank C] iileclronic Lille Leak ))(:lector, Q Tank (gauging Probe.hnnislarSpacrr�ir Z Q Other (specify equipment type and model in'i"tio _+) i E Vattlt Sestsor. 1AttJel;(�17(pilgSModel)'ill'sanip Qt)ispenserCoittamnuntSeltsor(s). Model: hear Valve(s). Semor(s)• Model:0"Wchankill Line Ixmak l�tecior. Model: ] Shear V$Ivc(sl. Q l:ICClrtlnlC Z!1{C Leak IhdCCtltY. MLKIeI: Chain(s). M'rankOver(ill/High-ixvelSensor. Model: D Ocher (spcci(yequ,1pment type and model m Slcntln Uspenser to: ©))ispatscr('on(tiin . l t;.sarfs). ataJcl: ar Valvew. •pcmn;rCoalainntcat FIMN) and Chain(s)_ Dispenser ID: Q DispenserC'entainmentSen.%m(s). Model: ClShear Velvets). I: l Dispenser Containment I°loa((s) aftd C'hanH fl_ Dispenser 1D- 13 I)ispenscr('oltta67mclttSensorts). Modch Q Shear Valw(s), Q Dispunscr Containment !:loaf(%) six] Chain("). facility ct)ntainsmore tanks or dispensers, cops this Tank ID - 44n - Tank Gauging Probe. Mo(el; [Annular Space or Vault Sensor. Model: (7ipingSump /-Troneh Sensor(s). � Model: ' at Dill Sump Seasons). Model: �Mechanical Linc Leak Detector, Model: :lectronic Linc Leak f)etector. Model: (S'I'ank Overt)ll / High-Lcvul Seltsor, _ Aiodel: Q Other (SNCl6' cquipmen( type and model in Seeuttn ? o c 2). Tank ID: © In -Tank Gauging Probe. ,de (� Annular Space or Vault Sanstu. Model: ❑ Piping Sulnp /'I'rcnuh Scnsor(s). Model: ® Fill Suntp Sensor(s). Model: Q MCtdtanical Line leak Detcclor. Model: C] iileclronic Lille Leak ))(:lector, Q Tank Overfill I I ligh-Level Sensor. e : - Q Other (specify equipment type and model in'i"tio _+) i E Dispenser ID: 3 Ci Qt)ispenserCoittamnuntSeltsor(s). Model: hear Valve(s). jDispenser Containment Floats) and Chain(s). Dispenser ID; i] f )ispettstx Ctbltainmem SellSORS). Model; ] Shear V$Ivc(sl. © Dispenser C'onlainment Float(s) and Chain(s). Dispenser ID: Q Dispenser Containment Sensor(s). Model: Q Sltoar Valve(s), iJ Dispenser C'ontainlncni 11-oat(s) and Chnin(s). for every tank and dispenser at the Iltcilhy, 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 Infhrination Is -correct and a Plot Plan showing the layout of monitoring equ6 ment. for any equipment capable of generating such reports, I have.also attached a copy of the report: (cheek rill that applt): LJ System set_pp ] Alarm history report Technician Name (print): GABRIEL VENEGAS Signature: Certification No.: 1340893 — � � License. No.: "Testing Company game: _L.0 SERVICES T _ Picone No,: (5139) 4""730 _ %sting Company Address: 3887 N VAL_ ENTINE FRESNO CA 93722 Date of Testing/Servicing: _. �q— Page 1 or 3 Rev (2/08) 01 W