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1—Od-202 8:26AM FROM SACRAMENTO EMC 918926281E R- 2 <br /> MONTTORINd SYSTEM CERTIFICATION <br /> For Use by All Jurisdictions Willtia the State of Califomis <br /> Authority Cited:Chapter 6.7.Health and Safety Codd;Chapter 16,Division 3,Tide 23,California Code of Regulations <br /> This tbnn must be rued to document testing and servicing of rnomlorrrtg epuijinuin t,A saparte certification or report must be limpued for each rnonitoWsymcm control <br /> Penc]by the technician who performs the work. A Dopy of this form mrut a provided to the tank systemowner Maatot. The ovrtter/oputtlor must subnnt a Dopy ofthis <br /> form to the local dgrncy regtllatirig UST systems withtng 30 days of test date- <br /> Facility Name FGU Sltoctdon Service Center-PGE094 Bldg No. <br /> Site Address; 4040 West Lane City: Stocllton zip 9$201 <br /> Facility Conrad Person: 209-942-1426 Contact Phone No.: JAM Jarvis <br /> M3kr/Model ofMnpitoring System: Universal Leak cat-GAO$ Date of Tcstinc,/Scrvicing; 11/01101 <br /> 13. lnventory of 13quipment Tested/CerHfted <br /> Tank ID, Waste Oil W&I Tank ID: Hydraulic OU Model <br /> 1n-Tank.('waging Probe to-Tmtk Gauging Probe <br /> '%nnular space of Vault Scasof LALSl o" Annular Space or Vault Sensor Lu S1 <br /> Of Piping Surnp/Trench Selmor(s) LALSt r Piping Sump i Trench Smsar(s) 1.AI.SI <br /> Fill Sump smu''(a) - Fill Sump Sesser(,) <br /> Mechanical Linc Leak I)ctccwr lvfecbmical kine Le L;Detector <br /> Moet*=Linc Leak Dczo= Electronic Lute Lack Detactvr <br /> Tardc CNcrf,11/11igh-text Sensor Shleldx Fbper TDl0 -r Tank to ertt11/yigh-level 5anwr Shields Harper TD10 <br /> 2(specify equipment type and model in Section E on pOther 2 Pec*equipment type and model in Sectico E on <br /> Tank ID: ) blodcl Tank ID: ) . xlel <br /> Tn-71mk Gauprng Probe In-Tank GatV%Probe <br /> Annultc Space or Vault Sensor Annular Spar or Vault Sensor <br /> piping Sump I Trench Sensor(%) Piping Sump!Trench Sensor(s) <br /> n11 Sump Se or(s) Fill Sump Scncct(s) <br /> Mechanical Lira.Lank Dctucur Maehanieal Line Leak Derr-etor <br /> F.I ca nic Line Leak Daccwr Electronic Line Leak Ddoctar <br /> Tank CNerfil[/fligh.levcl Senenc Terilc 0vcrfiL1Migh4evd.Sensor <br /> OffieP ag <br /> r <br /> 2(.;Mvify equipoa mt type and model in Section 9 on �(spec4 equipment type and model in Section B on <br /> ) 22)) <br /> Digpenser ID Mr-del Dispenser ID Model <br /> Dispenser Containrnc=Senscr(a) Disperesar Conwmcat Scser(s) <br /> Shear Valvas) Shea Valve(s) <br /> Dispenser Coarairi mens Float(a)and Cbraiw(s) Dispenser Containment Float(s)and Chains(a) <br /> Disp=tr ID Model Dispenser M Mnde1 <br /> Dispenser Conminmc=Setuet(s) Dispenser Contairmtertt Senser(s) <br /> Shear Valve(s) Shear Vilve(S) <br /> Dispenser C,,niamrnent Moat(,)and Qtams(t) Disparwv Ccmtautrncnt Flom(s)arid.Chauu(s) <br /> C. Ccrtilliication•I certify that the equipment identified in this dommem was inTccted/serviced in accordance with the manufac rurer.R'guidelines. Attacked to this <br /> Certification ie intbrrrtation(c. Manufacturers'ehedclietc)necezary to Verify that this informat information is correct and a Plot Plan showir4 the layout of monitoring <br /> equipment. For soy quipincrif of gancrating such reports,I have also z ached a copy oftho(chock all that apply): <br /> Syt=n act-uF tcpxt(attached) (No printer) Aim=histoy report(auarhed) (No pnincr) <br /> Technician Name(print)Jinn_Retching CexVLic.No; Signature; '—E1 ry-N "11:r acs,i <br /> Vesting Company Name; Sacramento Equipment Maintenance Company,Inc. Phone No. 916-925-2716 Work Order# 106605 <br /> 03101 county/000 flstate/I-morutonrRg CMWj5d Page 1 af4 <br />