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1 1 L01 B'_ :1 rrl/rorlh� C'itet/: (�7raoer 67, ;-JW17 and Cot r,/uq)1(r l f� L'rvr it „ s, r ,;, This form must. be used to document testing and servicing�o`�'� of monitoru3g equipment. A separate certification urrejort must be prepared for each monitoring system control panel by the technician who performs the work. A copy of i#1-11,�Itug*rovided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local ageiT systems within 30 clays of test date. Lam.. EVIR , A. General Information FacilityName: ;moi i S•t Add - 4/w) V_ P,+9 Qiclk I ritIALI N ERMlT/SEVICE Bldg. No.: i e i ass. Ct 1 L �i City:-r,)oC.t +t .n Zip: Facility Contact Person: �.��*� Contact Phone No.: ( Make/Model of Monitoring System: Date of Testing/Servicing: 3- / /1—/ Uk B. Inventory of Equipment'Tested/Certified Cheek the a2proeriate boxes to indicates ecitic a ui meat ins ectad/service T, k ID: n-Ta;ilc Gauging Probe. Model:// anular Space or Vault Sensor. Model: y 'ping Sump / Trench Sensor(s), Model:] OF- ❑ Fill Sump Sensor(s). Model: +Mechanical Line Leak Detector. Model: __,$F" ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. odel: ❑ Piping Sump / Trench Sensor(s). Mo ❑ Fill Sump Sensor(s). Mo ❑ Mechanical Line Leak Detector. del: ❑ Electronic Line Leak Detector. odel: 0 Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Paee 21_ ID: ®- Z Ta Ic ID: y/ ❑ Annular Space or Vault S --Tank Gauging Probe. Model: 6 ❑„Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: � ❑ Fill Sump Sensor(s). Model: rl7Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Paee 2). Tank ID: In-TankGauging Probe.Xtor.Mod ❑ Annular Space or Vault S ❑ Piping Sump / Trench Se ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak D ❑ Electronic Line Leak Det ❑ Tank Overfill / High -Level Sensor. Model: A,Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser ID: „s?�"y Dispenser Containment Sensor(s). Model: Z�� Shear Valve(s). ❑ Dispenser Contaimnent Floats) and Chain(s). Other (specify equipment type and model in Section E on ipenser ID: 7 J" ,Dispenser Containment Sensor(s). Model: Shear Valve(s). !=senser Containment Float(s) and Chai D' penser 1D: f =® G Spenser Containment Sensor(s). hear Valve(s). ❑ Dis enser Containment Floats) and Model: �S.F � enser ID: •s Di enser ID: �%/'.-/Z Dispenser Containment Sensor(s). Model: Z�I�' Dispenser Containment Sensor(s). Model: Zcaf- hear Valve(s). Shear Valve(s). ❑Dis enser Containment Float(s) and Chaint.0 ❑ Dis enser Contaimnent Floats) and Chain(s). *If the facility contains more tanks or dispensers, copy this torn. Include informati_wLfor eve tank and dispenser at the facility. .dP�rJPPGCA - 1 %1A vy, C. Certification - I certify that the equipment identified in this doeuhtent was irspcc ed/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 apply): ❑ System set-up ® Alarm history report Technician Name (print): Vi 10 ,`n kJF Signature: Certification No.: �Y'�7j.® ;r -d OL Z' S2 4,3 3173--C1T License. No.: 19 - Testing Company Name® i tLt i!r a&ji 5 g Phone No.:( (; 9 Site Address: 1-/t(0j )�®rhe- S" r.j��lu� e� Date of Testing/Servicing: S— l Jl_/0 ?- Page I ol'3 Monitoring System ('ertification z Q3/o t