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MONITORING SYSTEM CERTIITCATTON For Use By All It risdiccions Within the Stare of California Authority Cited:Chapter 6.7.Health and Sqfery Cade:Chapter 16,Division 3,Tide 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A seoarate certification or report most be pronated 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 ownerfoperator. The c wner/operator must submit a copy of Us form to the local agency regulating UST systems within 30 TIME OIL 04-049 14000 E. HWY. 88 Bldg.No.: LOCKEFORD, CA 95237 City-- Zip: Facility Contact Person: Contact Phone No.:(--) y Make,Model of Monitoring system:_ .a Date of TestingCServicing: __5ij of(75 B. Inventory of Equipment Tested/Certified C4eckthe appropriate hmmsto- toui menuuripectedfservi d: Tank ID: Tank ID: IG '�- ht-Tank GaugingProbe. "• ModelCu-Tank Gauging Probe. Model: Ammlar Spic or Vault Senor_ Madel:L.,9- _. Annular Space Or Vault Semar. Model- Piping Sump/Trench Sensor(s). Model: '�}'` Piping Sump f Reach Senmr(s). Model: .r ❑Fill Sump Smsce(s). Model: 0 Fill Sump Senaor(s), Model: 0 Mechanical tine leek Detector. Model: G Nis- 9 Mechanical Line Look Detector Model: _— ❑rlecoonkUnoleakDetector. Model: U P.iccuouic Lint Ltak Damm_ Model- 10 Tank-Overfill C Rtgh-Level Sensor. Model: d Tank Overfill/Legh-Level Sensor. Model: 0 Other(specify wt c and model in Sarion E on P 2). ❑Other( equipment and model in Section E on Page 2). Tank ID: T=k]D: Ia-Task GaugingYmbe. Model: d'Vlf.++`'> ❑InZaak Gauging probe. Model.- Annular odel:Annular Spam or Vault Sensor. Madel: .7-- ❑ Annular Spaceor Vault Sensor. Model Piping Sutnp/Trench Sensor(s). Madel: r1 . ❑Piping Sump f Trench Sensot(s)_ Model: Q Fill Sump Sensor(s). Madel: - ❑ru sump srnsor(s). Model: if Mechanical Line Leah Detector. Model- N`'' ❑Mecbanicsd ISae IaakDetector. Muriel: ❑Eccuoufe Line Lack Detector. Model: ❑ Elecamac Line Leak Detector. Model: i{Tank Overfill f High-ravel Sensor. Model: ` ❑ Tank Ovotfill C ltigh-Csve(Srncor. Model Q Other( ui amt and made]in Section,E on Paan 2)_ D Other(sRoodY CqUiP-- and model in Section E on Pate 2). Dispenser ID: : -.. art bispenserConminment Seasor(s). M r!D=LTCwtaiumen[Seaseu(s) MoldlC. e- Sbdr Valves) ear Vaive(s� Dis Conraumeat Reacts)and Chatu(s). Coni ament Aoar(s)and Chain(s). Dispenser ID: •y"__ r/ Dkpenser ID: Dispense(-'pnfoinnm�l Seosot(s). Model: r ❑DtgasrsuCaominmr�t Sensor(s)- Model: Sleet Valves) U Sbear vaivats)- _42ispenser Conraimurnt Floats)and Chain(s). ❑ Dispeosor Containment Floats and Chain(s). Du-peiser ID: "5 Dispeoser2D: DispeaserContainmv�t Sepsots)_ Model: ` r( ❑Dispenser Coaramment Sends). Madel Shear Va)ve(s) ❑Shear valve(s). iVenstr Cotetaioment Foat(sl and Cham(sl. Q Dispenser Containment Floats)and Chain(s). `If the facility contains mora tanks or dispensers.copy this form. Include information for every tank and dispenser at the facility. C. Certification-!cottifp that the equipment identified in this document was impeetedfserviced in accordance with the romanducturers' gtdddiam Attached to this Certification Is information (e-g,manufacturers, checklists) monsary to verify that this information is correct and a Plot Plan showing the layout of motdmring eRmynent Fah my equipantramble of generating such reports,I have also attached a ropy,of the r (' nun C): lEnystrin set-up port Technician Name(print): cdt`te. Signature: "".v, '"^•• �.�.. .. . Certification No.: License.No.: 10 Testing Company Name: t- ✓f/( -TF C Phone No.:CLez? ) y &"CO 15 Site Address: l L!® G j"rl.+�U ,�(� h (-,. 1� Date of Testiar/Serviciag:y�/L/ 0S Page 1 of 3 97101 Monitoring System Certification