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MONITORING SYSTEM CERTEFICATION For Use By All3urisdictioru Within rite State of California Authority Cited: Cltaprer6.7. Health and SgfetyCode: Chapter76, Division 3, Title 23, California Code ofRegulariotu This form must be used to document testing and servicing of monitoring equipment. A separate ecrtifrcation or report must bcprenaretJ for each monitoring systems control Panel by the technician who puforms 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 7ystems within 30 days of rest date. A. General Information Facility Name: Site Address: COUNTRY MARKET 1524 FRESNO AVE. STOCKTON , CA 95206 Bldg, No.: Zip: Facility Contact Person: /n1 Contact Phone No.: (__) Make/Model of Monitoring System: --_ C� � ✓I/C� Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to ' 'caiz c ui ment ' ected/set viced: tank ID: Tank ID: "-tikTn=Tank Gaugring Probe. Model: ❑ In -Tank Gauging Probe. Model: 12 a ular Space or Vault Sensor. Model: ❑ Annular Space ar Vault Sensor. Model: '5 l aping Stump I Ttr..nch Sensor(s). Model: ❑ Piping Stump I Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 'aMechanical Line Lzak Detector. Model: ! ❑ Fill Sump Sensorts). 0 Mechanical Line Leak Detector. Model. ❑ Electronic bine Leak Ducetor. Meda: — p� � �i<n t Overfill I Nigh -Level Sensor. Model: t�lttf�!_ Q etecu c Line L, -alt Detector. Q Tani, Model: Model: Overfill I High -Level Sensor. Model: ❑ Other (specify equiErnent tyEo and model in Section E on Page 2). ❑ Other (spacd (spec'aqui merit type and model in Section E on Page 2). Tan; Tsnk ID: ❑ In -Tank Gauging Probe. Model: ❑ in Tattle Craugiag Probe, Modal: 0 Annular Space or Vault Sensor. MQdc�: Q Anular Sgocc or Vault Sonsor. Model: ❑ Piping Sump I Trench Smsotis). Model: U Piping Stump I Trcnch Sensor(s), Model: Cl Fill Sump Sensor(s). Model: Q Fill Sump Scasor(s). Model: ❑ Mechanical Line Leak Detector. Model: Q Mechanical Line Leak Detector. IMGdel: Z) Fdcaronic lana Leak Dt lomor. Medd: ❑ Electmnic Line Leak Detector. Modc1: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Leve] Sensor. ModeL Q Other(sped, cquipmentequipment and model in Section E on Paan 2). ❑ Other (s ui menu and mode) in Section E on Paoe 2). Dispenser ID: A— p efspenser ID: patent Sensor(s}. Model` — speasa- Containment Sensor(s). model. Q Shear Valve(s). Shear Val e(s)- ear Valve(s). ❑ 1jispenzerConminment Roat(s) and Chain(s). Dispenser Containment Floats) and Chain(s). Dispenser ID: —Dispenser �� W. upensee Containment Sensor(s). Model, - Ll Dispenser Containment Seawr(s). Model: D:Shear Va]vtls). U Shear Valvo(s). __Q_Diuser Conmranent Float(s) and Chain(s).❑Das er Containment Floats and Cbain(s). r Dispenser ID: — Bupcases2lJ: I�Dispenser Containment Sensor(s). Model: Shur Ll Dispenser Containment Sensor(s). Model: [' Valve(s). Q Sbew Valve(s). Ctrs nmr Containment Roat(s) and Chuin(s). Dis ser Containment Float(s) and Chains). If the facility contains mora tanks or dispenser& copy this form Include information for every tank and dispenser a; the facility. C. Certification - I certify first the equipment identified in this documeut was hxspeeed/serviced in accord;artce with the manufacturers' gtudeliues. Attached to this Cerii6cadw is infoz7natiou (e g. msntttaciatrrs' checkhsir) aeeessaxy to Verity that this inforutation is correct and a Plot Plan shaving the layout orMeAtoring For any c� attached a co cif the ° " 1 e to such >�� I have also NameKj(check all that aPFfY1t t S3`�m set-up m o report Technician Name Q � � t i111'-(�, t .•r` Signature: Certification No.: Licenses No,: Testing Company Name; �`��['� Phone NoJ 70 eZ Sit, Address: 15 2 (' P `? U Ave � J -i t � r �° � ')y' � Date of Testing/Sin king: i`age 191'.3 03/01Monitoring System Certnteafian