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MONi.. ORING SYSTEM CERT1 4;ATION For Use By All Jurisdictions Within the State of California Authority Cited.- Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Site Address: COUNTRY MARKET 1524 FRESNO AVE. STOCKTON , CA 95206 Bldg. No.: Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: ;e'p /,.PYA? _ Date of Testing/Servicing:/ / O� B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate speciit5c equipment inspected/serviced: Tank ID:v/&-52-- 1,Tank ID: V -hi -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: wiping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ,Wc'Mechanical Line Leak Detector. Model: c l ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other specify e ui ment t e and model in Section E on Page 2). ❑ Other (!2ecify equipment type and model in Section E on Page 2).. Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: 1 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑Tank Overfill / High -Level Sensor. Model: LJ Other (specify equipment e and model in Section E on Page 2). ❑ Other (s ecif equipment t e and model in Section E on Pa c 2 . penser ID: — Dispenser ID: Af ispenser Containment Sensor(s). Model: 9—p Dispenser Containment Sensor(s). 91 Model: hear Valve(s). ED Shear Valve(s). is enserr Containment Floats and Chain(s). ❑Dis enser Containment Floats and Chnias . Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: !2X::3Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s), u the tacnay contains more tanks or dispensers, copy tlus form. Include information for every tank and dispenser at the facility. C. Cern' ication - I certify that the equipment identified in this document was inspected/serviced in accordance with the manuf cturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this inform tion is correct and a Plot Plan showing the layout of monitoring equi ment. F r anyuipment capable of generating such �& a report , I have also attachA a copy of the report; (check all that apply): st et- /rm history report Technician Name (print): E I r'Ae:lf CPSignature: �... Certification No,; License, No.; Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Site Address, IS L A F9—SfNQ 1 'FG0z f Phone No.: (707) 446-6151 Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification