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MONITORING SYSTEM CERTMCATION For Use By All larisdirtions Within.the Sore of CaVornia Authority Cited:Chapter 6.7.Health and Safety Code:Chapter 16.Division 3,Tide 23, Californio Code of Reguladow This form most be used to document testing and servicing of monitoring equipment.A separate certification or report most be Prepared for each monitoring system control panel by the technician who performs the work. A copy of this form mast be provided to the tank system ownerloperator. The owner/operator trust subunit a copy of this form to the local agency regulating UST systems within 30 days of test date. RAPID SERVICE CENTER CARDLOCK #1004 A. General Information 3550 HWY 99 Facility Name: STOCKTON, CA 95215 — Bldg.No.: Site Address: _- — _ Zip: Facility Contact Person: Contact Phone No.: MakdModel of Monitoring System: -7-k-c<Vj -/ s / 000 Date of Testing/Semcing: I�l/ _ B. Inventory of Equipment Tested/Certfiied Checkth.aPirzapriatoboxesto' 'ca'3e c ni men ins ectedtserri d: Tank ID, 3iZTan1TGauging Probe Model: ✓//Ltic X3 In-Tank Gauging Probe, Model: ��?'alar Space or Vault Sensor. Model, <S(�Annular Space or Vault Sensor. Model:�'ping Sump/Trench San sw(s). Model: Me7Tt 4 .hipmg Sump 1 Trench Senser(s). Model: A` 0 Fill Sump Smsor(s). Model: 0 Fill Sump Sensor(s). Model: ❑ Meduaical Line Leak Detector. Madel: 4�`Mechanicat Line leak Detector. Model: + -- ❑ElectroniclineL&akDetector. Moder: O Biecnonic Lunt Lank Detector. Model: .Tank Overfill/High-Level Sensor. Model: LlrTaok Overfill 1 High-Leve Sensor. Model: �a 0 Other(s 'tv ui meat te]in Section E on P 2. D Other(specifyequipment t and model in Section E on Pa 2). Tank ID: and madTank ID: .Mk-Ar Tank Gauging ProbeVault Model: nom.rt ❑ tn-Tanknular GaugSaceot Probe. Model: 151:/vmuWr Space or Vault Sensor. Model: ❑ Angular Space or Vault Sanest. Model: .. Z�'Pipiag Sump/Trench Sensor(s). Model: Gin" ❑Piping Sump I Trench Sensor(s). Modal: Cl Rll Sump Sensor(s). Mode: O Fill Sump Sensor(s). Model: tr-Mechanical Line Leak Detector. Madel: (- Cl Mechanical line Leak Detector. Model: El Electronic Line Leak Detector. Modal: O Electronic Line Leak Detector Model: -eTank Overfill 1 High-level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: P other 'Egipment and model in Section E on Pave 2). D Ofharlfs=equigniaratand madel in Section E on Page 2). Disperser ID: Dispenser ID: D Dispenser Containmeat Sensor(s). Model• U Dispanser Cmitainnunt Sensor(s). Model: Shear Valve(s). 3-Shear Valve(s). A�;Nspensar Containment FlP-Dispenser Containment Floats and Chain(s). Dispenser ID: — Dispenser M. U Dispenses Containment Sensor(s). Model: ❑ Dispenses Comainmem Seasar(s). Mode: likShear V4ve(s). O Shear Valve(s). Vl user Containment Float(s)and Chain(s). ❑ Dis ensu Containment Floats and Chain(s). Disperser ID: Dispenser ID: ❑ Dispenser Containmeat Swsm(s). Model: Ll Dispenser Containment Sensor(s). Model: when Valve(s). O Shear Valve(s). Lk user Containment Roat(s)and Chain(s). Q Disperser Containment Float(s)and Chain(s). -If the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser a the facility. C. Certification-I certify that the equipment identified in this document was inspecteNserviced in accordance with the manufacturers' guideline& Attached to this Certification is information (e.g, lnann[ettmrrs' checklists) uecm to verify that this information is correct and a Piot Plan showing the layout of monitoring equipment- For any bleage, g such reports,I have also k� attached a copy of the re K;(check ail that apply): �c system set-up rt.. --- """ Technician Name(print): b e t 1't Er.,{E'f Signature: ` J Certification No.: License.No.: Cr�9,. Testing Company Nance:� L � Phone No.:(5_) Site Address: 3950...-H w S T'O C -+,O N Date of Testiog/Servicing: ?j11-/� Page L of 3 03/01 Monitoring System Certification