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Q 4 T Dispatch MONITORJNG �'YSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safely Code; Chapter 16, Division 3, Title 23, California Code of Regulations Chis form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be oreuared for each nonitorine system control oanel by the technician who oerforms the work. A copy of this form must be provided to the tank system owner/operator. Che owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. k. General Information �acility Name: ��(} Ll� Bldg.No.: Site Address: -2-L-2 i vo th city: C,4 zip:Q11 3I(_{1 'acility Contact Person:, � *�1 -tl i sl^tContact Phone No.: vlake/Model of Monitoring System: ;e hs'1 ID c�7 Serial Number gf-') Sate of Testing/Servicing: _/C!t, 9 3. Inventory of Equipment Vested/Certified 4c Z heck the ageropriate boxes to indicates ecitic ui meat ins eeted/serviced: rank ID: T'j /-16;5 y 'Tank ID: l L 7 7 7747 D In-Tank Gauging Probe. Model: ❑ In-Tani:Gauging Probe. Model: a Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: "Q-Piping Sump/Trench Sensor(s). Model: :—f its-Piping Sump/Trench Sensor(s). Model: `7 y�V,3'20-5 3 mill Sum Sensor(s). Model: ??r,; F� p r( ) -7 7 9.g 61C) .?Z Sump � '' ? C�•-Fill Sum Sensor(s).. Model: '- :3 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 3 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: :3 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ZI Other(speciLy eoui anent type and model in Section E on Page 2). ❑ Other(specify SquLpment . e and model in Section E on P 2). Tank ID: 7S 7/ Wank.ED: Z] In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ZI Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: R-Piping Sump/Trench Sensor(s). Model: )-��. 3 ❑ Piping Sump/Trench Sensor(s). Model: 3-Fill Sump Sensor(s). Model: 41'? G- Z ❑ Fill Sump Sensor(s). Model: :1 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: :3 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ZI Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: :1 Other 12ecify a ui ment a and model in Section E on P e 2). 1 ❑ Other( ecify Nuipment type and model in Section E on Page 2). Dispenser IID: X0, Dispenser IID: S- ❑ Dispenser Containment Sensor(s). Model: y v M- 3 2 3 ❑ Dispenser Containm t Sensor(s). Model: 'Z 5�el3 6C -,T z_3 :3 Shear Valve(s). ❑ Shear Valve(s). ❑ Dis eraser Containment fjo2gsj and Chain(s). ❑ Dis eraser Containment Float(s)and Chain(s). Dispenser ID: -' Dispenser ID: /Z ❑ Dispenser Containment Sensor(s). Model: , q"6y 3 ❑ Dispenser Containment Sensor(s). Model: 7 y y 3 S s '� Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: U/,rJ ❑ Dispenser Containment or(s). Model: "J y V s c Q--3,2-,; ❑ Dispenser Containment Sensor(s). Model: 7,'It 00 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Floats 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 all that apply): ❑System.set-up ❑ Alarm history report (print): � �-� gn ` Technician Name rust : o�'�:~✓ 11j ';"//, _,____ Si afore: Certification No.: 1-x_3 17✓ Z License.No.: 302015 Testing Company Name: CHARLES E. THOMAS COMPANY Phone No.: 310 ) 323 6730 Address: 13701 So. Alma, Gardena, California 90249 Date of Testing/Servicing: 6 Page 1 of 3