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Monitoring System Equipment Certification For Use By All Jurlsdletiom Within Tire State of California rilrthOrlfy Cited' Chapter 6 7, Health and Safety Cods,, Chapter 16, Divlslon J, Tule 1J, Colijnrnio Code ojRegulallons This form must 6c used to document testing and servicing of monitoring equipment. A separate ccrtificati nor .Pnnrt mart preaarad for each monitorine system control m ��! by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. T?re owner/operator must Submit a copy of this within 30 days of tell date. form to the local agency regulating LIST system A- General Information Facility Name: Chet/ 30-1709 AM No.: Site Address: 10858 Trinity pkwy City: Stockton, CA Zip: 96218 - Facility Contact Person: -- r Contact Phone No.: 209 962-2213 Make/Model of Monitoring System: V VZ S- Date of TesringJ$ervieing B. Inventory of Equipment Teased/Certified Check the appropristt born w iodkate tptdtk eaninam.r i.a. "i,,...t -.e. TaID In - - Q 'tank Gauging Probe. �nnulsr Space Vwlt Sensor. Model r,..k 1rn - Talk Gauging �� Dobe. Model. or til"'P ping Sump 1 Trench Scnwr (s). Modcl• Modcl: 2 Y Annular Space or Vault Sensor. Modeh jc QrPin Sump Sennet (s). c Model:_ S' Q/p tpin)< Sump 1 Trench Satsar (s). Modal: Q Mtohanical Linc LeakDcDetector. rYt lutronic Line Lsak tectar. . Model; Model.- Fill Sump Sensor (s). Modal. ❑ Mcchaniea) Liner Leak Daector. Model: Electronic Line ❑ Tank OverflN \ Higll_t.evel Scnsor. Model; Leak Detcewr Model: a n'ha (�fy equipment grye and model in Section Eon Page 2). ank v O ❑ ❑ TankOverfill l hi�►l-Level Senor. Model: easilyui W Pmeat type and model in Seeiion E on Pace 2). TStrk )n - Tank Gauging Robe. Modc1, Tank 11D_,!� ❑ to -tank Gauging Probe. Modcl: Q/ War Space or Vault Sensor. rag Sump 1 Trrnch Sensor (s). Model: y— 4 Modal: p Annular Space or v.,h smor. Model: Fill Sump Senear (s). Model: a O Piping Sump 1 Torch Sensor (t). Model: ❑ Multanical Linc LuY DeaaelOr. D"EIceYrOnic Linc Le k Data Model: 0 Fill Sump SMSW (s). Modal: ❑ MaCAanieal Line teak Detector. Model: tor. ❑ Tank Overfill \ High -Level Sen". Model: S1el�iil Model: 0 Elachonie Linc Lcak Detector. model: ❑ Other ( specify cquiprelcnt rype and mOdct in SOction E on Page 2) 0 rank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Samar E on Page 2) p) neer CD: f —L_ Disprnscr Containment Sensor (s) Heeler: vary Dlapeeur CDS]— Y D' [Y�hcar Valve (a> @/ Conuinwsent Srnstr (s). Model: p�shear Valve (s). El Dispenser Containatrau Float (c) and Chain (s). ❑ DisPc— Carat» nMCAl Floor (a) and Chain (s). Dispenser CD — tet ConuuirrrextI Sensor (S). Model. D penser m. _ 0 p�ispenttet Cohuinrnent Senior (s). Model: tY Shoff Valve (f). ❑ D(fpl5hsa Coumuunmt Frost (s) and Chain (s). Qr Shear Vatm (sl Cl Dispenter Conieinareni Float (s) and Chain (s). Dispenser 1D• — V Dlspcnscr Containment Sensor W. Model Dispenser 1D•( Shear Valve (s) 2ti L7/-- Dispenier Containment Sensor (s). Model )p 0 Shear Valve (s). ❑ DOWASW containment Float (s) and Chain (I). ❑ Uisocnser Contunlnent Float (s) and (:hien (il. • 1{ Ili. 1'v:l'.. -i>tteoseri, copy tnls form. Include Intev.nat,on for every tank i.d dispontel a rhe facilely C. Certiilc"On - 1 certify Ilial the egdrpaOW 11124iii3ed in iL:jj document was lasp"Ic%vaerviced in aetnrdaner witu rnr maaufscturer's euidtliats. ,vroched to thls (ertlflucioo is InfOrmbitiOn (e.g. nanufdelureA' ehcckiisss ) necaaary to venty that this inrnrmaNnn 4 correct •■d a Prol M■. 5"wlmy, tht layoit of monitoring equ�t For an) equip I capable of gewratlag Such reports, 1 have ales aNached a cupy or flu; (eAtr4 dlt MM deed); ysata feFap oeeAlar history repot C, T•cchnician Name (print): Jerry Sanouvang Signature: Mfg, Cert,q,; letYi License. N01485184 Testing Company Name: SSS Picone No.: (408) 871-2446 Tasting Company Address: 880 Quinn Ave., San Jose, CA 95112 Date of-resting/Servicing: L6 39dd bZb86899161 TETT 9T9Z/8Z/S0