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MONI RING SYSTEM CERTIN TION se By .ill Jurisdictions 111itllin the State of Cali. , is .duthority Cited: Chapter 6.7° Hearth and Safety Code; Chapter /6, Division 3, Title 23, California Code 6FJgtdn io '3 This form must be used to document testing and servicing of monitoring equipment. A separate certify CkrWW1 69_ -{ prepared for each monitoring system control panel by the technician who performs the work. A copy of this fo ��10&PV , o the tank system owner/operator. The owner/operator msubmit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: 7P -,J (=S Bldg. No.: Site Address: / G //ca . City: e_ -,q -7,' Zip: Facility Contact Person: Contact Phone No.: (G �-� )- Make/Model of Monitoring System: j® 7L• j� � � Date of Testing/Servicing: «/ / C, B. Inventory of Equipment Tested/Certified Check tile aeproeriate boxes to indicate s ecitic a ui ment ins ectedtseryiced: Tank ID: 1 Tank ID: / - -�Nn-Tank Gauging Probe. Model: at��c, / 1� Annular Space or Vault Sensor. Model: 49 -In -Tank Gauging Probe. Model: y' 49,•Piping Sump / Trench Sensor(s)- Model: �AMUIar Space or Vault Sensor. d Piping Model: c , 2 ❑ Fill Sump Sensor(s)`.. Model: Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). Model: Model: 0 -Mechanical Line Leal: Detector. Model:Tte ) .Mechanical Line Leak Detector. Model: El Electronic ic Line Leak Detector. Model: LI Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor, Model: ❑ Other (specify equi meat ty e and model in Section Eon Page 2). ❑ Other (specify equipment ty e and model in Section E Tank ID: �,/ n -Tank Gauging Probe. Model: Tank ID: on Page 2). I:Annular Space or Vault Sensor. Model: e? T C> ❑ In -Tank Gauging Probe. Annular Space or Vault Sensor. Model: —El N:LPiping Sump / Trench Sensor(s). Model: 4 8 ' ❑ Piping Sump / Trench Sensor(s). Model: Model: ❑ Fill Sump Sensor(s). Model: gif-Mechanical Line Leak Detector. Model: �=" �w;Z ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify e uipment ty e and model in Section E on Pa 2). ❑ Tank Overfill / High -Level Sensor. ❑ Model: e Other (s ecify equipment t E on Pa e and model in Section e 2). Dispenser ID: ZYCDispenser Containment Sensor(s). Model: Dispenser ID: ispenser Containment Sensor(s). Model: A::Sliear Valve(s). ❑ Dispenser Containment Float(s) and Chains) shear Valve(s). er ❑Dis enser Contaimnent Floats) and Chain(s). Dispenser ID: •i,' 'C1,Dispenser Containment Sensor(s). Model: Dispenser c:> tihev Valve(s). ❑Dispenser Containment Sensor(s). Model: ❑ Shear Valves) ❑ Dis enser Containment Float(s) and Chain(s). ❑Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ,LDispenser Containment Sensor(s). Model: ? terry' ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). ❑Dispenser 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 bfor every tank and dispenser at the facility. 51 'C 4- / " - /1-J. I, �, _tom C. Certification - I certify that the equipment identified in this ocument was inspectedtserviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' cheeldists) 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 drat apply): System set-up larm history report Technician Name (print): AVi 12 L Signator : Certification No.: 3 ✓�7'3-ar License. No.: ATL � n $— I Testing Company Name: /y r bA TE5 p-• Phone No j tog %'��% - 6 Site Address: /Gj fry ; rj �� Date of Testing /Servicing: -/�/ Page i ol'3 f!3/Ot R'Ionitoring System Ccr•tilic,rtion - _ - _ ___ D. Results ccf Testis-/ Servichpo-