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MONIAING SYSTEM CERTIFOATION 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 of Regulations t'''his form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared 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/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information RAPID SERVICE CENTER CARDLOCK#1ooa Bldg. No.: Facility Name: 3550 HWY99 STOCKTON, CA 95215 Zip: Site Address: ---- — Facility Contact Person: Contact Phone No.: O `_ Make/Model of Monitoring System: ro V S 100� Date of Testing Servicing: vI ll B. Inventory of Equipment Tested/Certified Check the appmuite box;W indicate s cite niment ins ected/serviced: Tank ID: ` e %-- Tank ID: Tank Gauging Probe. Model: �yC/t� _ In-Tank Gauging robe. Model: ❑ Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: iping Sump/Trench Sensor(s). Model O Piping Sump/Trench Sensor(s). Model: ❑ Fill Sum Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: P ) ❑ Mechanical Line Leak Detector. Model:�_ L Mechanical Line Leak Detector. Model: Cl Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 2 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipme4ge and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Tank ID: Tank ID: in-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Ltl Piping Sump/Trench Sensor(s). Model: :j:jQAt-F ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: l&I Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: If Tank Overfill/High-Level Sensor. Model: A ❑ Tank Overfill/High-Level Sensor. Model: ❑ Others ecif equipment a and model in Section E on Pae 2). ❑ Others ecia equipment t e and model in Section E on Pae 2). VTDispenser ser ED Dispenser ID: enser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: ar Valve(s). Shear Valve(s). Containment Float(s)and Chains . Dispenser Containment Float(s)s and Chains . Dispenser ID: '" Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Flo a s and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: L iDispenser ID: ❑ Dispenser Contaminant Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: % Shear Valve(s). ❑ Shear Valve(s). Dis enser Containment Floa s and Chain(s). U Dispenser Containment Floats 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 P t Plan showing the layout of monitoring equipmenaForn p qu ent capable of generating such reports,I have also attac d a op f er�eport; eck all that apply): ❑ Sy 'p f/LJ�Atarm histoTechnician Name(print): rrbZ/G Signature: – CortlfioatlonNo,; Livense, No,; g� Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No.: (707) 446-6151 Site Address: `1-1 ` Date of Testing/Servicing: % Page 1 of 3 03/01 Monitoring System Certification