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PCE V EU MAY 2 6 2009 *.. STEM CERTIFICATION MO MaNK11", ins Within the State of California Authority Cited:Chapter 6.7,HeaChapter/6,Division 3, Title 23, California Code ojRegulations 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 N l Facility Name: L�t lJ ' v Bldg.No.: K dL C� C Zi . y—'37 Site Address:,Z��C ;hc1{1t-Xl -0,r)V _ City:- Q Facility Contact Person: ) t � L �k ��'�Nnk, Contact Phone No.: �I� 3 y" �a d Make/Model of Monitoring System: l�if'h�� - t y� Date of Testing/Servicing: S—)il/-95 B. Inventory of Equipment Tested/Certified Check the a ro nate boxes to indicate s ecific a inment ins eted/serviced: Tank ID: `' Jzz Tank ID: In-Tank Gauging Probe. Model 94 a3 —oto "14.2� 'd In-Tank Gauging Probe. Model: 3z-OL -" Annular Space or Vault Sensor. Model -so 3o??_ Annular Space or Vault Sensor. Model:: atl�t-3 Ate- �oZ Piping Sump/Trench Sensor(s). Model: 4/ 4.-�G-& 1 Piping Sump/Trench Smsor(s). Model:�_-W Fill Sump Sensor(s). Model'7c,4�L.1'1. E3 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor. Model: N Tank Overfill/High-Level Sensor. Model: � ❑ Other(specify a ui ment DZe and model in Section E on Page 2). ❑ Othereci wi ment wDe and model in Section E on Page 2). Tank ID: >- Tank lD: ff In-Tank Gauging Probe. Model:�,'7 3 �W- t Ll In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: y,4= _ o'Z ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 4 � ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: Q Tank Overfill/High-Level Sensor. Model: Cl Tank Overfill/High-Level Sensor. Model: Cl Other(specify equipment a and model in Section E on Page 2). ❑ Others i e ui ent a and model in Section E on Pae 2). Dispenser Dispenser ID:k` ID: C " .Cp Dispenser Containment Sensor(s). Model' Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain (s). 13Dispenser Contain t Floats and Chain (s). Dispenser ID: 6 -UP Dispenser m: Dispenser Containment Sensor(s). Moder 9 Dispenser Containment Sensor(s). Model: J Shear Valve(s). ❑ Shear Valve(s). l7 Dispenser Containment Float(s)and Chain(s). ❑ Distienser Containment Floats and Chain s). Dispenser W: Dispenser ID: 0 Dispenser Containment Semor(s). Model: I] Dispenser Containment Sensor(s). Model: i] Shear Valve(s). ❑ Shear Valve(s). ODis nser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats and Chain(s). *If the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the facility. C. Certif ration-I certify that the equipment identified in this document was inspected/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 equutipment capable of generating such reports,I have also rep attached a copy of the ort;(check all that app ): $a System set-up g Alarm history Technician Name(print): t ( S CL Es\ Signature: ,-`-� tLtj� Certification No.: 5 Z S A S(o D-t tT License.No.: 491948 Testing Company Name: Central Petroleum Maintenance Phone No.:(925 462-4060 Site Address:L-7w i'✓V 5- 7- - Date of Testing/Servicing: UN-036-1/4 Page 1 of 3 Rev.06/04/01 www.unidoes.org