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MoNTTORING SYSTEM CERTIFICATION <br /> Far Use By All Jruisdict(ons Within the Score of CaW¢omia <br /> Authariry Ch-ed:Chapter 5.7.Health and Safety Code:Chapter 16.Divitinn 3,1 tthe 23,Celiforria Cade oJRegtdmians <br /> Thus form roast be used to document testing and sen'icing of monitoring ring A arate crttifirstion or rcoort nmst be arcnared <br /> orms the work. A copy of this form most be pmvtded to the tanl. <br /> for each rttonirorih w* rnmrol Hanel by the technician who perf ro acing UST systems within 30 <br /> s,m m ownerloperator. Tire ovmcdoperntar mrrct submit a copy of this form ro the local ageneY gtu - -_.. <br /> days of test date. -. ---A. General Information TIME OIL 04-049 No.: <br /> Facility name: 14000 E. HVVY 88 <br /> i <br /> Site Address: LOCKEFORD, CA 95237 P <br /> Facility Contact Person: Contact Phone No.: <br /> C (��_-------- <br /> Date of TestinglSetvicing: <br /> MakdModel of Monitoring System: S lls> — -B. inventory of Equipment Tested/Cert►fied <br /> t�ktbe - mama ia&ole <br /> Tack m: - _. Madel ('H.Io-Tadt Cwgmg probe. Maw= <br /> _�I.IuTmk 5rgtngProbe. }i`t ft SPaa err V wlt Sensor- Model <br /> A- ®m/Tr Vau Sasor - Model: _ - to Piping Soma I hack Smsm(s). Mft �t <br /> U rill' sump S=mr(s). Mand: t7 Fdi Sump Smmrts)- Model x\ <br /> l .Mxhaoirat line I,rslcDa - Mudd= �T� - {-(,. j�Mpd�dlyteltakDeteax- Model- <br /> ❑0cmu is lint I=kDcvsrm. Model: U. eleatodcLinel.emkDerertas- <br /> �� Uf Tmk OveM l lh&rI.evel Smsor. Model- �'- <br /> �Tank OvtrfiIl!Fhgh-level Sensor. Mudd:� twe and model in Section on 3). <br /> 00d=( and model in Semm 2). 0 Otlrt i <br /> specEry <br /> Tank1D: <br /> •. ank ID- <br /> Dok Gm - Probe- t'la e 0 h,-Tauk C>mVn Pmbe- Model <br /> �i Amalar Sp=or Vmh Sensor. ModcL. O Aomdm Spaaar Vmilt Seamy. Madel <br /> I Trmcb Swsa(s). Model: ❑Piping Scoop/Trench Seasm(s). Model: <br /> El FilI S Smsot(s). Mode: t7 FA saw Sr»(4 Model <br /> - CTS- — ❑M lice 1=kDewctor. Mode): <br /> pMecbemtallmeLe*Detector- do3d= ;j, E)ecannic lmel akDetecmr- Model: <br /> 0 Elocaoaic Linc Irak Vd=or, <br /> Moder: <br /> 0 Tank Ovuhn I S8h-Level Sensor- Model: �'n 0 Tmk Overfill t}Sg)*Imd Smror- Model <br /> and model in Seelim Em 2)_ OOdc( and ro Ael in Section Eon Paan 2). <br /> 0 p�COMKWMSmmK%). Model: <br /> ❑D)spmsa Cmmmt�Smzm(s). Madel: Shamvmhv(s} <br /> Q Shm Vahe(s). - C tFlox(s)md t3ainls} <br /> Cam Ftoat(s)asd(yain(s). <br /> Dispenser 1D: <br /> t Dispema m: -'� 0 Dispenser Oomamm ma seasor(s). Model: <br /> q: Q Cor4ai Smsor(s). Model: t. <br /> 0 Shear Va1*4 Sim Vis)_ <br /> Cha Aom(s and 212i"(51FtFl,IN Comarmsmt Aon(s)am Cbero(s)- }a' <br /> Dapamse ID: ❑❑ Comainmrm Senvu(s)- Modrd: <br /> 0 Dispmsa Cowmtm mSmsw(s)- Madcl: Cl Shear Vehc(sl <br /> 4 ❑$tear Va1ve(51 0 - emtanmmt Flat(s)and Clan(s). <br /> t'I - sett cement Finatts)and ispmu(s). <br /> 'If the facdiry contains mmimla or dispmser,copy this corm. Include information for every tank and dispenser a:the facility. <br /> C. Certifit�tioD-I ceriifi mat me eq�meffi idem(fied In the dacr�stns iredtsgv �ardao a wim the man dadnrers' <br /> Lnuddiues. Attached to this Cerafreadon is i corm ttea(egf mstmmamvvs ) rree,� to vergt that mis information is <br /> mrrtlY zod a P1otPlm stowing the Iapoat o[tnm>•a�B - For trop etp e sub r"mlsr I lam also <br /> attached a copy ofinetgPmc�(tJt�t aR tltm a�pt9): 'Systemgnahp �Alar�b <br /> Tecimirian Dame(print): Signature: <br /> I <br /> Certification No-: <br /> )-L4 - . <br /> Tasting Company Nmne. < ` <br /> Site Address: I QDDE t'FwS4 SS C.csr.Y_e-�ri�d 45z3� nneafTaungrsa. ns:fir- f31D�- <br /> page 1 of 3 001 <br /> Monitoring System Certification <br />