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SYSTEM CET,-, & t Ise By ;l%Jzn z ztu:/run, II«hrrz tMc "tal 4zrthority Cited: Chapter 6.7, Nen th and Safety Code; C'hat)ter 16, Division 3, Title 2.3, C�11ilbrnia Code of Rc-, rut;�rrs This form must be used to document testing and servicing of monitoring equipment. Ase ar< certification or report must be prepared for each monitoring system control panel by the technician who erforms the work. A co p f �m �trtvided to the tank system owner/operator. The owner/operator must submit a copy of this form to the loc within 30 clays of test date. -=z h� iy f A. General Information A4AYB 2 2008 Facility Name: C9 �j Pis Idg.No.: Site Address:— L/f��y �t''✓y�i?r'� S� City: S E'i' �. , Facility Contact Person: $t. Contact Phone No.:( Make/Model of Monitoring System: -T" :r Date of Testing/Servicing: B. Inventory of Equipment'Tested/Certified Check the aepropriate boxes to indicatespecific equipment ins ected/seryiced: FT•nk ID: 97®C}- Tank ID: In-Tank Gauging Probe. Model: Z ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Z LJ Annular Space or Vault Sensor. Model:Piping Sump/Trench Sensor(s). Model: Z Ll Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: �Ytviechanical Line Leak Detector. Model: I ,)0 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify e ui ment type and model in Section E on Page 2). ❑ Other(specify a ui ment type and model in Section E on Pae 2). T k ID: Tank ID In-Tank Gauging Probe. Model: Z ❑ In-Tank Gauging Probe. Model: 13 Annular Space or Vault Sensor. Model:_ S�11+ ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model e ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Y1 e)()o 13 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: LI Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify a ui ment t e and model in Section E on Page 2)_ ❑ Other(s eci a ui ment type and model in Section E on Pa e 2). Dispenser ID: l Dispenser ID: b Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model- Ed Shear Valve(s). 8 Shear Valve(s). ❑ Dis eraser Containment Floats)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: , Dispenser ID: 9 Dispenser Containment Sensor(s). Model: � ari Dispenser Containment Sensor(s). Model ® Shear Valve(s). Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)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 Float(s)and Chain(s). ❑ 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 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 a//that app/6): W System set-up ®Alarm history report Technician Name(print): ` AV)o � t`y�kl� Signature: „_. Certification No.: tf 9 .,,T ..,. � 52 73'llT License.No.: /I Testing Company Name: r'�r t�F1 5'T 2U Site Address: `7/u(� ✓ Date of Testing/Servicing: 11 / / Monitoring=,_System Cee•tifisa son Page 1 of3 113/U 1 � . Get=,aiith, of Tesf.tpz,;/crviceag