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MONITORING SYSTEM CERTIFICATION ?or Use By All Jurisdfctioru Within the State of Ca4fornia Authority CitMd:Chaioter6.7.Health and S*ry Code:Chapter 16, Division 3,774,-23, California Code of Regulmions This form mnsebe rued to document testing and servicing of monitoring equipment Q separate cortification or renon must be nrepmA 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/ope utor. The owner/operator must subunit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information TIME OIL 04-049 Facility Name: 14000 E. HWY. 88 . Bldg.No.: Site Address: LOCKEFORD, CA 95237 _ Zip; Facility Contact Person:_ l Contact Phone No.:(� MalkelModel of Monitoring System: Date of Testing/Servicing: L_44' 11y k B. Inventory of Equipment Tested/Certified Check the approptiate bma:s to io& ie x equipment iasrecteaterymed. Tank M: - '. Tank ID: :_ , n-Tank Gauging Probe. --Model: .CLt-Tank Gauging Probe. Model: o*rAanutar Spam or Vault Sensor. Model: *�Adwular Space or Vault Sensor. Model: Ll 2V Piping Sump/7rench Srvrsor(s} Model- -UPipmg Sump/Trench Sensor(s). Model: U Fill Swap Sensor(s). Model: U Fill S lir lechanical Line Leak Detector. Model: amP Sensor(s).LeModel: �echauieal Line LeakDeteaor. Model: S 06ankve Line Look l val Se. Model: O 'e Line Leak Detector. Model:�L }�78nk Overfill!Ffigh-Leval Sensor. Model: Xr-Tank Overfill/FIigrt-Levet Sensor. Model:--�/��/+�y�J�— U Other(s 'fv ui t and model in Section E on P 2). U Other ' equipment t and model in Section on Pae 2. Tank ID: Tank W: ID: )kln-Tank Gauging I'mbe. Model: U Annul k Spacn tg I'rohe. Model: ,�Armulor Spoce a Vnult Sensor. Model, Q Anoulaz Spencer Vault Sonanr. Model Q`Piping Sump t Trench Sensor(s), Model: U Piping Sump t Trench Sensor(s). Model: • G Fill Sump Sensor(s). Model:—�-�-t- Q Fill Sump Scasor(s). Model' ,Q Mecbanical Litre Leak Detector. Model: /-� Q Mechanical line Leak Detector. Modeh Q Hkxaouiclina Look Detector, Modd: U Elocnonic Lint Leak Detector. Model: P'Tank O%T fiH/High-Level Sensor. Model:__ ❑ Tank Overfill/High-Level Seusor. Model: U Other m i tin Section E on Pace^-). D Other(s eat and model in Section E m P 2). Dlspa*er)D: - and model Digp r ID: U Dispenser Containauent Sensors}. Model: D Dispasv Cm[aiamentSmux(r). Model: �� ;,Q:Shm Valve(s). Arsbear Valve{s). _Q�Nspexnea Contatnmant Ftoat(s and C'hain(s). ;Zt Disptur=Containment Flow(s)and Chains. Disperserm: - Dispenserup. U Dispenser Containment Sen s). Model: Q Dispenser Conwinmeat Sensor(s). Model• ;EKShear Valve($). U Shear Valvgsy �kl>ispanscr Containment Fl s)apd Gain(s). ❑ Dispeastr Contaisment Float(s)and Chain(s). DLspeaser ID: Dfape meriD: Q Dispenser Containment Sensors). Mork}: \ / ❑Dispenser Containment Sensors). Model: Shear Valve($). U Shear Valve(s). nser Containment Roat(s)end Chain(s). Cl n' ser Containment Ruat(s)and C(rain(s *If the facility contains mom tanks or dispensem copy this form, include information for every tank and dispense,at the facility. C. Certification-I certify that the equipment identified in this doctameat was itupectedlserviced in accordance with the manufacturers' guidelines. Attached to this CerfrFicatian is information (e.g.merwfactnrcrs'cbecklisu)aecessaxy to vecit'y that this information is correct and a Plot.Plan showing the k"ut of monitoring egrtipmeiu. For any equipment capable oferating swb reports,I have also attached a copy of thetepom(clteclr as that apply): ysteat set-up ,a Alnted iifstorvt(,ottbrt TecbnicianName(print): i�4 Signature: Certification No.: license.No.: RQ�7QJ Testing Company Name; / ✓i {'�. -� . K Phone No.:( P_7 ) -y�V0_&IS/ Site Address: Date of Tc*dr lScni king: l(r:/ ,��'/L'_' 1' Yap I of 3 03NI Monitoring System Certifieafiun