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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Stare of Cahforrsia Authority Cited:Chapter 6.7.Health aaCt foery Code:Chapter 16,Division 3, Tide 23,Californio Code of Regulations This form mast be wed to document testing and servicing of monitoring equipment.A separate canification or report must be urepared for each monitoring system control panel by the technician who performs the work. A copy of this form most be provided to the tank system owner/operator. The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. Ge. Facility TIME OIL 04-049 Bldg.No.: 14000 E. HWY. 88 _ Site AdLOCKEFORD, CA 95237 ty Zip: Contact Phone No.:(, Make/Model of Monitoring System: t ✓ � — Date of TestingtServicing) B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicateui men[' eded/serviced: Tank ID: Tank ID: VIn-Tank Gauging Probe. Model: a B-:In-Tank Gauging Probe. Model: 4 @,Annular Space or Vault Sensor. Model:� 0 Annular Space or Vault Sensor. Mode): kt 76 0 Piping Sump/Trench Sensor(a} Model: 20 ,aPipiag Sump/Trench Seosor(s). Model: 0 Fill Sump Sensor(s), Model: 0 Fill Sump Sensor(s). Model: Q Mechanical Line Leak Detector. Model: _ff l ,0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Deventer. Model: 0 Electronic Line Leak Detector. Model:-- a Tank Overfill t High-Level Season. Model: OkTsak Overfill I Iligh-Level Sensor. Model: 4a R 7 0 Other(s ecifv equipment t and model in Section E on Page 2). 0 Other(sptcja(spec' equipment t and model in Section E on Pae 2). Tank ID: Tank ID: 60 In-Tank Gauging Probe. MoAW D In-Tal:Gauging Probe. Model: 0 Annuls Spam or Vault Sensor. Model: 0 Annular Space or Vault Sensor, Model: 0 Piping S"/Tm=b Sensor(s). Modol: 0 Piping Sump/Trench Sewor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Smsor(s). Model: 0 Mechanical line Leak Detector. Model: 0 Mechanical line Leak Detector. Model: 0 Electronic Linc Leak Detector, Modpl:.� � 0 Electronic Line Leak Demeror. Model: 0 Tank Overfill/high-Level Sensor. Model: 0 Tank Overfill i Iligh-Level Sensor. Model 0 Other(wedh,eniairimcrit type and model in Section E on Peae 2). D Other(sm and model in Section E on Page 2). Dispenser ID: I Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensou(s). Model: R Shear Valve(s). 0 Shear Valve(s). ® Dispenser Containment Filoat(sl and Chain(s). WNDispensor Containment Floe s)and Ctwin(s). Dispenser ID: Dispenser ID: 0 Dispenser Contaiameni Seasor(s). Model: 0 Dispenser Containment Seasor(s). Model: lb Shear Valvo(s). - c0 Shearvalve(s). ig Dispenser Containment t Pl s)and Chain(s). 121-Dispeater Containment Floar(s)and Chain(s). Dispenser ID: Dispenser 1D: 0 Dispenser Containment Sensor(s). Model: 0 Disp user Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). UlDispenser Containment Fi s)and Chains. 0 Di ser Containment Floac(s)and Chaiu(s). *If the facility contains more tanks or dispensers,copy this Iona. Include information for every rank and disperser ai the facility. C. CettlflCatiOn-I certify that the equipment identified in this document was hapected/serviced in accordance with the manufacturers' gufdelh� Attached to this CertMeation Is information (eg.mauufacturcrs' edieckksts) necessary to verity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the rep ,�checf;.pli that apply): asystem set-up (Q A - report Technician Name(print): 0'h,t //I((�'��(( 'L Signature:t-----i' �1^�� Certification No.: Z 2 a S ahaa T 1[ License,No.: % _1' r57�Z_ Testing Company Name:` f an K.- / t� r 1 t-. �l Phone No.:�1_�,� Site Address: 14000 E H W T 31f )-och&Fo f G Date of TestivieSetvicing: /_Q21 Page 1 of 3 03/01 Monitoring System Certification -