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MONIt6RING SYSTEM CERTIFWATION For Use by All Jurisdictions within the State of California Authority Cited: Chapter 6.7, Health and Safeb, 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 Signature: Facility Name: YELLOW TRANS. Bldg. No.: Site Address: 1535 E. PESCADERO AVE. Cit :TRACY Zi :95376 Facility Contact Person: RICHARD Tank ID: #6 OD. WATER SEPERATOR Contact Phone No.: ( ) Make/Model of Monitoring System: ®In -Tank Gauging Probe. Date of Testing/Servicing: 44-05 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ms ectemservicea: Signature: Certification No: 4307 License: 814027 Testing Company Name: ShirleyEnvironmental I Tank ID: #5 WASTE FUEL Address: Tank ID: #6 OD. WATER SEPERATOR NIn-Tank Gauging Probe. Model: MAG 1 ®In -Tank Gauging Probe. Model: MAG I Z Annular Space or Vault Sensor. Model: 303 N Annular Space or Vault Sensor. Model: 302 N Piping Sump / Trench Sensor(s). Model: 205 N Piping Sump / Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: _ E]Fill Sump Sensor(s). Model: F1Mechanical Line Leak Detector. Model: _ ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: _ ❑ Electronic Line Leak Detector. Model: N Tank Overfill / Higb-Level Sensor. Model: OPW Z Tank Overfill / High -Level Sensor. Model: OPW ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment a and model in Section E on Page 2). Tank ID: SOAP Tank ID: _ ❑Gauging Probe. Model: _ ❑In -Tank ing Probe. GaugIn-Tank Model: N Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: _ N Piping Sump / Trench Sensor(s). Model: 205 ❑ 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: N Tank Overfill / High -Level Sensor. Model: OPW ❑ Tank Overfill / High -Level Sensor. Model: _ ❑ Other (specify equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). Dispenser ID: Dispenser ID: _ ElDispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensor(s). Model: _ ❑ Shear Velvets). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: _ [__1Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: _ _ ❑ Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Senaor(5). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). If the facility contains more tanks or dispensers, copy tars tom. include information for every ianx anu unspun= mi wu <acuuy. 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 the information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also ....L..d _ ......I ..r the re - aiva tk an brat anntvle F— System set -tip n Alarm history report Technician Name(print): ROY WALKER Signature: Certification No: 4307 License: 814027 Testing Company Name: ShirleyEnvironmental I Phone No.: 909-476-7443 Address: Date of Testing: Page I of 3 Monitoring System Certification 03/01