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MONII&UNG SYSTEM CERTIFWTION 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 nof�Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certifi t� [>p! �eliai for each monitoring system control panel by the technician who performs the work. A copy of this form t =" system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 da of test date. A. General Information OCT 2 0 �09 Facility Name: 76- Bait & Tackle Site Address: 574 W. Grantline Facility Contact Person: Ramesh Make/Model of Monitoring System: TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins cted/seryiced: ENVIRONUEALTN or-ranjR. -P!.Q City: Tracy Zip:753 6 Contact Phone No.: (510) 828-2266 Date of Testing/Servicing: 10/8/2009 Tank 1D: Super Unleaded TanklD: Regular Unleaded ® In -Tank Gauging Probe. Model: 847390-209 ® In -Tank Gauging Probe. Model: 847390-209 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD -2000 ® Mechanical Line Leak Detector, Model: STP -MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: "rank 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: ❑ 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 equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ® Dispenser Containment Sensor(s). Model: 208 M Dispenser Containment Sensor(s). Model: 208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) 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. Certification - 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 equt meat. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): S tem s t- p /N Alarm history report Technician Name Gavin Williams Signature: 6i Certification No.: 8016288 -UT License. No.: 856771 Testing Company Faure: U :"C - l;enderson Maintenance Company Phone No.: (209) 467-7573 Site Address: Date of Testing/Servicing: 10/8/2009 Page 1 of 3