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1-04-202 8-28AM FROM SACRAMENTO EMC 9169252816 P- 6 <br /> MONITORING SYSTEM CERTIFICATION <br /> For Use by All]urisdictiom Within the Stott of Califmniu <br /> Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Divitlion 3,Title 23,California Code of Rcgulationa <br /> This fain must be u-%cd to doCUMent Luting axed scavicing of monitu nng eitpmcat.A sepatte ccrtificelion or rgxrt must be prepared for each monitoring synem control <br /> ppond by the tcchnieian who performs thn work. A copy of this foals mist bee provided to the tunic sy=m aamer7operater. The owner/operator must submita copy of this <br /> form to the local agoi y regulating LIST sy&temz.wit}ung 30 days of teat date- <br /> Facility Namc PGF.-StoelaoA Service Ctnter-PGF094 Bldg No- <br /> Site Address: 4040 West louse city' Sterclaon zip 51.5201 <br /> Facility Contact Person: 209-942-1426 Contact Phone No.: Jim Jarv6 <br /> Make/Nlodel of Monitoring Systan; veeder-Root TLS350 Date of Tcating/Sorvicing: 11/01/01 <br /> B. l,rvertrnry of F yuipmrnt TestedlCertlGal <br /> 1� cagipmcnti L% 4t 'CC <br /> Tank M: tlnleed(87) Modal Tank 10= Dksael Model <br /> J In-Toa&G'-tlB Probe 4847390-106 J In-Toatk Oaugiag Probe 0947390-106 <br /> ✓ annular Spare or Vault Sensor 0794390-420 ✓ str"ar Sparc or vault Senior 0791390-420 <br /> ✓ Piptrg sump!Ttcnch Samoa(s) 0794.80.208 J Piping Sump/Trench Sewcr(s) 0794380-208 <br /> Fill sump Sensor(s) Fill Sump Sensors) <br /> Moch+ui-J Linc Leak Dcto t— Mkbha —1 Line Lcak Detector <br /> ✓ Electmnic Linc Leak DetccLm 0848490-003 ✓ Electronic Line Lank Detcetor 0848480-003 <br /> T r+k CXwfilVHiglt-level Senwr Tank Ovrsfilll sh•lcvcl Sensor <br /> Other(spccify equipment hype and model in Secum P on Other <br /> (vwify cquipmuu type and tn+3del in Section 8 on <br /> 2) <br /> 7 szk]D: Model Tank Il)', Model <br /> In-Tmk csugwS Probe In-Tank Galling Probe <br /> Annular Sparc cy Vault Sensor A.nnalar Space or Vuult Sensor <br /> Piping Surq/Trench Swor(s) Piping Sump/T-D&S__(s) <br /> Fr11 Sump Sensor(%) Fill Sump Sarisca{s) <br /> Mechanical Line Leak Detector ?Mechanical Lite Le4k Ddedar <br /> ]ilreCronic Linc Lcuk L�etawtQs Eleetroma Lino Leak Detwtaar <br /> Tank fhcrfilVHigt-level Sensor Tank Ove6WHigh-level Smscv <br /> Gthtr specify equipment type and model in Sarum F.m Other(specify equipment type incl model in Section E on <br /> Page 2) Page 2) <br /> Dispenscr W NOL102 (Gas) Model Diapaocr 11) ao3m4((res) Model <br /> J Dispaiser Cotitninmrnt Scnacr s) 0794380-208 1 Dispenser Gcowrimeni Scnact(g) 0?94180-208 <br /> J Shear vol e(s} (om J Shear valve(:) (oPvt>) <br /> Dispenser Caiitainmem Floats)and Chaim(s) Dispenser Containment Float(s)and Chau;s(s) <br /> llispcascr ID *01/02(Diesel) Motel Diapensa ID lvfodel <br /> J Di%p.=&Comtainmcra Sonar(%) 0790.180-208 Disrpamcr r ew�t Sc naer(s) <br /> ✓ shear Vasva(a) shearvalve(s) <br /> Disper=Contain mu t Float(s)and Chaiw(s) Dispaasa COMA nrnent Flwt(%)and C.iiauts(s) <br /> t, CcrtilfiCation•1 certify that the equipment identified in this document was inspectc&%aviced in acoorcimce with the xnanafacbm=s'guidelines. Attached to this <br /> Certification is infoamauon(e. .manufacturers'dmidins)neomsary to verify that this information is correct and a Plot Plan showing the layout of monitoring <br /> equipment. For any equipment capable of 6encrating such repomq,Ihsave also attnahed a wpy of the(check all that apply): <br /> oe Syv-_setup report(aasched) foloft J I Alarm hkttay taport(attached) <br /> Technician Name(print)Jim Hutchins Cert/Lic. No: Signature: 77 Yyyi �-4rQh t ria <br /> Testing Company Name-, Sacramento Equipment�Ma nit nan e Cbo any,Inc. Phone No. 916-925-2716 Work Order#P106605 <br />