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VIONRECENEDD MONIARING SYSTEM CERTIFIC9 1--or Use 6v,-111,J11riSdiC1iO11s JOthin the.State ofcalrfbrnifl UAjffl9 ,4ulhoril.v Cited: Chapter 6.7, Health tnid&!kV('Otle; ('holVer 16, Division j, Title 23, Calijbl-170('o( Y'euj/i2 form must be used to document testing and servicing of monitoring equipment. A separate cert'fic-Awo.,ni;XF-oxt.iwgit"V, This monitoring system control panel by the technician who performs the work. A copy of i-I, 9 prepared for each i age'lon-URN111s the tank system owner/operator. The 111LISt submit a copy of this form to the localg within 30 days of test date. A. General Information lAA0 -t!q.610fl- MO.No.: Facility Name: AS KTA- Zip:City: A/ Site Address: VAI-r 157r -5-ri�r- *Z� Facility Contact Person: Contact Phone No.:(_7�)_ ing/Servicin" Monitoring System: D I of Test 140 �6_ Make/Model of Mol 40e B. Inventory of Equipment Tested/Certi fled Cjjccj.the a l-opriate boxes to indicates ecific equigment insgected/serviced... Tank I D: % Tank ID:— A?7-- Qr—;-r In-Tank Gauging,Probe. Mode JQ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: IN Annular Space or Vault Sensor. Model: ME Piping Sump/Trench Sensor(s). Model: lXL Piping Sump/Trench Sensor(s). Model: Q Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s), Model: P(Mechanical Line Leak Detector. Model: k-,DTOCNP� ;A Mechanical Line Leak Detector. Model: LJ Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: Q Tank Overfill High-Level Sensor. Model: Q Tank Overfill I High-Level Sensor. Model: Tank uI, rin Piping Swap �e 2). El other(specify equipment type and model in Section 1.oil Pa 0 Other(specify e in Cnent type and model in Section E on Page 2) .T ID: Tank ID: Tank an Probe. Model: C3 In-Tank Gauging Probe. Mode: Z,,In-T k Gauging C Q Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: AL Piping Sump/Trench Sensor(s). Model: C Ll Piping SUMI)/Trench Sensor(s). Model: I— Q Fill Sump Sensor(s). Model: • Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: • Mechanical Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: • Electronic Line Leak Detector. Model:X -Level Sensor. Model: • Tank Overfill/High-Level Sensor. Model: U Tank Overfill/High CI Other(s2ecify equiernent type and model in Section E on Page 2). Q Other(specify equipment ty e and model in Section E on Pae 2). Dispenser ID: Dispenser ID: 7— Sensor(s). Model: 91 Dispenser Containment Sensor(s). Model: 91 Dispenser Containnient Lit Shear Valve(s). 20 Shear Valve(s), CI Dispenser Containment Float(s)and Chain(s). 0 Dis2enser Containment Float(s)and Chain(s). Dispenser ID: 3 -1-T Dispenser ID: _T It IQ Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: &Shear Valve(s). &-Shear Valve(s). U Dis2enser Containment Float(s)and Chain(s). U Dispenser Containment Float(s)and Chain(s). DispeDispenser ID: t Dispenser I D: Dispenser Containment Sensor(s). Model: LI Dispenser Containment Sensor(s). Model: Shear Valve(s). Q Shear Valve(s). ense nser sir Containment Float(s)and Chain(s). U Dispenser Containment Float(s)and Chain(s). M *Irthe 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.,-. 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 app(,): A S _k%Alarm history report Technician Name(print): :17"p 11j;djA%g4! Signature: (-�Cc W 92�33a% Certification No., License.No.: 61ri # 0-4 -I to I Name: *njSA'_)9_)'7J I Testing Company A r Sr Phone No-,,, - I Site Address: Ilm-02 AW-ft6& - SWIS Date of Testing/Servicing: Page I of3 03101 Monitoring System Certification D. Results of Testing/Servicing,