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MONI HUNG SYSTEM CERTIFI&TION For Use By All Jurisdictions Within e th St t C a e of altfornia Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This 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 Facility Name: Ernie's General Store Bldg. No.: Site Address: 4407 E. Waterfoo Rd City: Stockton Zip: 95215 Facility Contact Person: MGR Contact Phone No.: ( ) Make/Model of Monitoring System: B. Inventory of Equipment Tested/Certified Check the anmmnriate hnrw to Date of Testing/Servicing: 1/15/2013 *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 Plot Plan showing the layout of monitoring equipm t. For any equipme capable of generating such reports, I have also attached a copy of the report; (check alt that appal: Yom"" stem set-up Alarm history report Technician Name Charles Ferrucci Signature �) Certification No.: B37512 lice, Na: 965Y0 Testing Company Name: Service Staion Testing, Inc. Phone No.: (209) 465-5577 Testing Company Address: PO Box 31465 Stockton, Ca 95213 Date of Testing/Servicing: Page 1 of 3 Rev (2/08) Tank ID: Tank LD. - :❑ 0In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sens ir(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ED Tank ID: ❑ in -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill; lligfi-I.evcS 8cn�m. Madel'. ❑ Task: Overfill { viigsA e m Srnsut. mvaet: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: PAC PRIDE 1/2 Dispenser ID: PAC PRIDE 3/4 ElDisperser Containment Sensor(s). Model:0 Dispenser Containment Sensor('s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: PAC PRIDE 516 Dispenser ID: PAC PRIDE 718 ❑ Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Contimn rtfiixks)aniGYraagr ). 0DpemwrQmGmneaFluat(s)and Cham(s). Dispenser ID: PAC PRIDE 9/10 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: I0 Shear Valve(sZ ❑ Shear Valve(s). ® Dispenser CoMainmem Float(s) and Chain(s). ❑ Dispenser Containment Float(s) 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 Plot Plan showing the layout of monitoring equipm t. For any equipme capable of generating such reports, I have also attached a copy of the report; (check alt that appal: Yom"" stem set-up Alarm history report Technician Name Charles Ferrucci Signature �) Certification No.: B37512 lice, Na: 965Y0 Testing Company Name: Service Staion Testing, Inc. Phone No.: (209) 465-5577 Testing Company Address: PO Box 31465 Stockton, Ca 95213 Date of Testing/Servicing: Page 1 of 3 Rev (2/08)