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Work Order: 2275500 <br />Monitoring System Equipment Certification <br />For Use By All Jurlsdicil Within RX State of Cahfornla <br />Authority Cited.' Chapter 6.7, Health and Safety Cade; Chopter 16, Division 3, Title 13, California Code of Regvianoas <br />This form must be used to document testing and servicing of monitoring equipment. A stPe ctnifi�uion n <br />trip aared for each m,xtitnnnO c. r rcnort mncr <br />m contrai tLn�l by the technician who performs the work. A copy of this form must be provided <br />to the tank system owner/operator. Typo owner/operator must submit a copy of this form Co the local <br />within 30 days of test date. agencY regulating UST syatern <br />A. GelerlalInformation <br />Facility Name: Chew 307708 <br />Site Address: 10833 Trinity Pkwy <br />Facility Con CCity:Hldg. No.: <br />: Stockton, CA Zip: 96219- <br />ty tact Person: r'Y—b / Contact Phone No.: 209 982-2213 <br />Make/Model of Monitoring System: ! VZ <br />H- Inventory of Equiptnewt Testsd)Certifled Date of Testing/Servicing S7, <br />Check the 1pPrODflltt horn m LaNnr.. A#6 "'_-_- <br />�•Y��• •��yRW Kr"IC[n: <br />Ta IDS <br />TPk r <br />- Turk Gauging �� Model: <br />a/in -'tank Gauging P Model'�"n <br />I�rmular Space Vault Scnsor. <br />or Model: <br />p"Piping Sump 1 Trench Srnsor (s). Model: Z c Y <br />eF'in Sump Senses (s). <br />Annulu Space or Vwjll Santo,. Model' js <br />Qr spiny IS1 Trench Sensor {sl Modal. <br />Model:_ � Sr <br />0 MaOhanical Lire Leak Dcicctor. Molt) <br />lirFill Sump Sensor (t) Mo& <br />Gi/Llcaronic Line Leak Dctcetot. Model <br />❑ Mechanical Line LAnk Demcxv. Model: <br />_ <br />L3 Tank Ovcrn I 1 lip -Level Sensor. Medd; <br />Electro is Linc I test, Detector, Mr : <br />q Oates (sPc6 taut mens <br />h D 0Pe and model in Section Eon Page 2) <br />❑ Tank (Tcrtlll 1 high.L.evel Sensor. Mold: <br />o (lptci h <br />equipmrnr type and model in Seehion C On Parc 2} <br />T k <br />I>2,_ <br />�Jn 'Tont G-Vng Probe. Modc1, <br />_ <br />InTank Gauging probe. Mo1ct: <br />ra�� <br />p� uW Space or Vauh Sensor. Model: 1'� 9 <br />hyping Sump 1 Trurch Senear (s). Modoi; <br />Jar Space or VMA Satsor. hfodcl: <br />Fill Sump Sensor (s). Model: <br />n8 SttntP 1 Tree" Sensor (s). Model. <br />a <br />❑ Mcchan" Linc LcAk O-cpoor. Model: <br />a Line Luk Date tar, Model: <br />Sump Srnsm (a). Model: <br />❑ Mechanical Linc leak Detector. Model: <br />o T Oveonic <br />Tank Ovufill 1 HiyA-Level Serotr. Model: <br />CJ Eleettonio Line Lok Dgotior, Model: <br />❑ Tank Overfill \ High-Lcvcl Scnsm. Model; <br />❑ OrAcr ( specify tquiprntnt type and model in Section Eat Page 2). <br />❑ orhu ( &Peary equipmard type and model in So¢ion Eon 'age 2). <br />Dii"nacr ID_ / `-t_ <br />4r Dicpuacr Contlithmcnr Sensor (s� Model: 245 <br />Dopeeur (D.7— Y <br />q/Srhw ViVve (s� � <br />�/DhSPratyti Ctlttltnwtent Sensor (s). Model: U� <br />V9Aear yet,,. (s). <br />0 Dispcnccr nta <br />Coinawu Floss (c) and Chain (f) <br />❑ Dttpsn Cr Containment Floral (t) and Chain (s) <br />Drajxwaar [D — <br />Contairunaoi Sensor (s). Model <br />Dr penser ID_g—!d <br />j'I ispau" Coinbeinment Sensor Modcl: <br />9 Shan Vslve (s). <br />(s). y(i <br />17 DirPeaser Caatainalrnt Float (s) and (Thain (t). <br />Q' ShC1r Vat.e (e) <br />❑ Dupmw Containment Float (s) and Chain (a). <br />Dis ser <br />Sensor (s). Model: <br />biapenaer 1D f!— <br />�DDcV�vCeoftemnaenl <br />( )_ <br />C3�Dispenur Containment Sensd (s). Model: )p <br />p1"Shear Valve (s). <br />O i IWASG Containment Float (s) snd Chain (c). <br />❑ Disocnscr Cnnninenent Flovh (s) and Chiin (cl. <br />•tfncc facility contains more hanks o, diltxru5 4 copy this forth Include <br />n ,tern et,on r every tank and dtsponter u the esti hly <br />C. Certification - i terrify anit the eguiprhtit hu`dGitd in ih;i Jocuracnr wet )ysP"lC%Vurviced in aeenrdaner wila rnr <br />ma.Ofatturers eaiddiAtt. Arnehed rn this Cerollcariou U Infafmatien (c.g. ■sahl faelurts' cartwisle ) nectseary to vcn(y he, this <br />infnrmatlnn {e cermet a.d • Plot PI.. arre.4n/ the layout ar, monlmrit>r, cqul t. for in) equiPI <br />r Capanlc of geutrsduk such <br />repent. 1 h..c .1w wsn cued a wiry or the; (cJ#Crk 011 Melt 4fM): 'ystc,e act -up Lr Cirrose "par <br />Technician Name (print): Jerry Sanouvong Signature: <br />Mfg. Cert.#.; ICC# License. No,: 5184 <br />'testing Company Name: SSS Perone No.:. (408) 871-2446 <br />'forting Company Address:_ 880 Quinn Ave., San Joae, CA 96112 Date of Testine/Servicing: u <br />L0 39dd <br />bZ786899T61 T£:TT 010Z/8Z/90 <br />Tanknology Inc. 11000N. MoPac Expressway, Suite 500, Austin, Texas 78759 <br />