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w . ROA AST 12 20 7 MONITORING SYSTEM CERTIFICATION For Use 13y All Jurisdictions Annin the State of California vF ERLTH Authority Citod:Chapter 6.7,Head and Safety Code;Chapter 16,Dlvision 3,'fide 23, Californk.Gude�Rioq'l Ili ui ment A separate certlticetion or report must be prepared for This form must be used to document testing and servicing of monitoring eq p each monitoring system control panel by the technician who psrforme the work.A copy d this form must be provided to the tank system Owner/operator.The ownWoperator must submit a copy of lois form to the local agency regulating UST systems within 30 days of test oate_ A. General Information, CJ9 91dg.No.: Facility NaNam*,. CNRvRON SKe Adder; 7501 17TM STREET City: TRACY CA zip: Contact Phone No.: ( ) Facility Contact Person: soots------------- gtekefMafel of Monitor5tlg System: TLS 3S0 [late of Testlrlg/ServicMg: 12193046 B. Inventory of Equipment Tested/Gertifiod Check the a ro date boxfls to indlCaW Specific a ul ment ins tUsorvlced: FpipIng Tank Size: - Tank ID: 99 Tank Slze: ingProtu. Model: ❑ In-Tank Gauping Probe. Model: e or VaultSensor. Madel: 420Annular apace or vault Sensor, Model: 420 !Trench 5ensor(a). Modal: Piping Sump 1 Trench Sensor(s). Model: Madel: ❑ pnsor(*). Modes: ❑ FRI Sump Senaor(s). ® Mechanical Line Leak Detector, Modal: 99LD 2000 ® Mechanical tine Leak Detector. Modal; 991-0Y000 ❑ Electronic Line Leak Detector- Model: ❑ Tank G ie unci Leak ayst SenDetector. Model; ❑ Tank OvwM 1 High-Level Sensor. Model: ❑ Tank Ospee f equipm nt Sensor. Moder: _ type and model In Section E on Page 2). ❑Other(speedy�IuiPn''eYrt IYPe and model in Section E rut Pegs 2), ❑ Other(specify equipment FID: ETankTsinK ID: Tank SiYo: gin4 Probe. M��: ❑ In-Tank Gauging Prone. Mafd: ❑ Annular Specs or Vault Sensor, Model: ce kx Vault Sensor. Model: SPI tT W 99 n Sump/Trench Sensor(s)• Mods1: /Trench Sensor(*). Model: P Pt gnsor(*)- Madel: [] rill Sump Sansor(s). Model: ❑ Medtenioel Line Leak Detector. Model: ® Mechanical Line Leak Detector. Model: 99LD x000 p electronic Una Leak Datector. Model: El ❑ ectronlo Line Leak Detector. Model: ❑ Tank OveTM I High-level Sensor. Model: d Tank (specsverfil/eHigh-LevelupnSensor. Model: s equipment and nwdU In Section E on Page 2)- ❑ Other(specify equipment typo And model in Section E on Pegs 2). ❑ Outer i, pecdy eQ Pln bps Dispenser 1110-. 1-2 Dispenser 113: 7-8 Dispenser Containment Sensor(s). Modes 208 ® Aispenser Containment Sensor(*). Model: 208 ® Shaer Val++e(e). CK Showvalve(s)• ❑ Dispenser Containment Float{a)and Cnaln(s), ❑ Dispenser Containment Floats)and Chain(s). 3�4 Dispenser ID: Dispenser 1D: TRANS 3UMP ® Diapenser Containment Sensor(*}. Model; 206 ® plopensef Containment Ssnsor(S). Model:208 ❑ Shear Valve(s). * Shear Valve(s). r Containment FWNWa)and Chaln(s). ❑ Dispenser Containment Floats)and Chaln(s). ❑ Drs{oertee Disp enser IP: 5.6 Dispenser ID: VAPOR POT ®Dlspenser Containment Sensor(*)- Model:420 ® penser Containment sensor($). Model: 208 Shear V81*5). ® Sneer valve(*). ❑Dispenser Containrnent Float($)and Chdin(s). ❑ Dispenser Containment F7oal(s)and Ghaln(a). -it the faCtlRy cartsins mote tanks a dispensers,copy this form. Include idfomta4on for every tank and dispenser at the tecHity. C.Certification-I cartily"I the vQ0Iprrrent idertttfled in thla document was lnspecppdfservraed in accordance vrifh the rnanufaoturera' Is rnf nRntlon(*S•rrrartufathuers'eheckliats)neceesaN to verify that this infpnnation is correct guideline&Attached to this CertlRcAft" l moot Por any epulpmarrt nl�ahla#generating each reports,l have also ettaetrad e and a Pot Plan allowing the IiAr of mpnt 0 usystem set-up ❑Alarm hhdory report capY of the rePOrfi(aSeclt all r&f�a9PNfi David Winkler Signature: Technician Name{print): T ic License No: 08-t739 Certiflcatfon No.: 52b337a UT phone No, 12M 744,0tt2 Testing Company Name: AFPORDA TEST Date of Testing1 c;ng: 12.16 2Die Testing Company Address: 4182" STRf ET GALT CA 95932 7J21/07 Monitoring System certification Page 9 of 3