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FROM :B.2.SERVICESTRTION MAIN- ANCE FAX NO. :916 371 2540 Aug. 07 2006 03:20PM P2 N.� lo/ MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7, Health and 5'gfety Code; Chapter 16, Division 3, 7'ifle 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separs e4,,,cenification or[MrE must be oreoared r each r gji4fjpg,,gySS€tE_control.nape)by the technician who performs the work. A copy of this form must be provided to the tank system owner/opmator, 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: C e jjm4Y P&,1,Z'h4i:- • _ Bldg.No,: Sito Address: /'7 8_ I W, C FlPIK-)`CiC City:_ �Tl� Zip: Facility Contact Person:�c2il- ,h t _ Contact Phone No.:rad)) 1y/4 Make/Model of Monitoring System: UECAPKIetds�i EMC_ Date of Testing/Scrvicing:0V4/_94� - B. Inventory of Equipment Tested/Certified CIrMk me a ro datt bozo w lodlcatt a title w ul mcnt Ina cc[ctlAerviccd: Tank ID: 7y _ yank lU: Arin-Tank Gauging Probe. Model:)%A2 a a Pil In-Tank Gauging Probe. Model: 41 nj Af Annulor Spew or Vault Sensor. Medd:e jai OZ V Ya* Id'Annular Space or Vault Sensor, Model: '7Lt A<Piping Sump/Trench Scnsot{s). Model:r&Q-L WtTlping Surnp/7rench Sensor(s). Model rouse 'O 0 Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: J1111 Mechanical Line Leak Detector. Model:f5?4,0 ZCr)O - ArMechanicalLine Leak Detector. Model: //E•-d.$.S ❑ lectronic Line Leak Detector. Model: O Electronic Linc Leak Dctoaor. Model: 21'1'aak Overfill/High-Level Sensor, Madel: o Qio" •OrTenk Overfill/High-Level Sensor. Model:�y2i72.l ❑ Other(specify ul ment type and model in Section E.. • on Page — ❑ Other(specify equipment ripe and model in Section E on Page 2). 'rank TD: Tank ID: O In-Tank Gauging Probe. Model: O ln-Taak GuugEg PrProbe. Model: O Annular Spree or Vault Sensor. Model;__ ., _ ❑ Annular Space or Vault Sensor, Model: O Piping Sump/Trench Sonsor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. model: O Mechanical Line Leak Detector. Model: O Electronic Linc Leak Dolcetor• Model: O Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Lovol Sensor. Model: ❑ Tank Ovcr.ill/High-Level Sensor. Model: ❑ Other(speci&equipment t and model in Section F.on Page 2). O Other(specify eclui meat=and model in Section B on PuRe 2). r §Di enser ID: '•�_ Dispenser ID: Dispenser Conminmoat Sensor(s). Model:FMArDispmsa Containnient Sensor(s). Model�+di..+� ;1> hear Valve($). 5Hhew Valve(s). ❑ Dispenser Containment Floatls and Chains). Ll Dispenser Containment F'loat(%)and Chuin(s). Dis user ID: -..,T. Dispenser ID: Dispenser Containment Sensogs). Model:Beg Y •a;!' '%t_, fa`Dispenser Containment Aensnr(s), Model• 0,�'S4YOdvd// ta'Shcar Valve(x). R'Shear Valve(s). O Dis enser Containment Pl s and Chain(s). O Dispenser t;oMainmont Floats and Chain (s). D-,irspenser ID: Dispenser ID: / By Dispm.wr Contuinin=t Senser(s). Model: Z ispcnser Containment Sensor(s). Modcl� '9.�aveCf/ fS1Shear Valve(s). At"Shear Valvc(s). ODis user Containment Flo s and Chain (s). 0 Dispenser Containment Floats and Chain (s). -if the facility contains more tanks or dispensers,copy this form Include information for every tankand dispenser at the facility. C. Certification -I certify that the equipment identified in this document watl inapoeted/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' check) ocessary M verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equip ent cap"Ne of generating such reports, I have also attached a copy of the report;(check all t at apply - System ect-up erns hlvt report, Technician Name(print): 1� Ki S _(d Signature: Certification No.: yo(f License.No.: 433159 Testing Company Name:_B.Z.Service Station Maintenance Phone No.:(-916_-_)-.371-23gQ_-• Situ Address: 630 Houston Street W.Sacramento,CA 95691 _ Elate of Testing/Servicing:0S/01-J.-Cv- Page 1 of 3 a3M1 Monitoring System Certification