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.QIL EQUIPMEN 1 SEHVIGt STATE LICENSE No.323417 CLASSIFICATION: A-HAZ.,C61D40 Division of Keith A. Tallia,% A ENVIRONMENTAL ASSESSOR No.01781 Telephone: (209)764-1008 Fax: (209)754-5726 Post Office Box 950 750 Industrial Way SAN ANDREAS,CALIFORNIA 95249 MONITORING SYSTEM CERTIFICATION 'chis form must be used to document testing and servicing of monitoring equipment. If nore than one monitoring system control panel is installed at the facility, a Separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of tlii3 form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this f rm to the local agency regulating UST systems within 30 days of test date. Instructions are printed on the back f this page. A. General Information Facility Name: Bob Cat Central Bldg.N .: Site Address: 1113 Shaw Rd. _ City. Stockton Zip 95205 Facility Contact Person: Don Franzia Contact Phone No.: ( 800 ) 2 6 —9631 Make/Model of Monitoring System: Incon TS 1000 Date of Testing/Servicing: 4 /9 /01 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: TanklD: Ti Regular Tank ID: T2 Diesel ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 90 Annular Space or Vault Sensor. Model:TS P iii S X] Annular Space or Vault Sensor. Model.TSP EIS W Piping Sumprriench Sensor(s). Model:TSP ULS X3 Piping Sump/Trench Sensor(s). Model--TSP ULS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: T.0 10 n ❑ Mechanical Line Leak Detector. Model: LS 3 0 0 10 Electronic Line Leak Detector_ Model(`am�OM,�_1_1 pr/_ Electronic Line Leak Detector. Model Cam OMi l l r R Tank Overfill)High-Level Sensor. Modcl:61 SODrop Tube )p Tank Overfill/High-Level Sensor. Model:6 DTO ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s)- Model: ❑ Shear Valve(s). ❑ Shear Valve(s). • Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Other(s ecify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Secti n E on Page 2). TanklD: T3 Waste Oil____ Tank ID: 3 ❑ In-Tank Gauging Probe Model: _ ❑ In-Tank Gauging Probe. Model: 1 00 Annular Space or Vault Sensor- Model:PetrOmeter/__ D .Annular Space or Vault Sensor. Model: D Piping Sump/Trench Sensor(s). Model: mid '20 ❑ Piping SumprTrench Sensor(s). Model: 3 ❑ 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: U Tank Overfill/High-Level Sensor. Model: ❑ Dispenser Containment Scnwr(s). Model: ❑ Dispenser Containment Sensor(s). Model. 't ❑ Shear Valve(s). ❑ Shear Valve(s). 0 Dispenser Containment Float(s)and Cliain(s). Cl Dispenser Containment Float(s)and Chain(s). U Other(specify equipment t e and model in Section E on Paec 2). ❑ Other(s ecifv c ui ment a and model in Secii It E on Paee 2). C. Certification - I cerlifv that the equipment identified in (his document was inspected/serviced in ace)rdance with the manufaelurers' guidelines. Aitached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Site Plan sho,cing the layout of monitoring equipment. For Inv equipment capable of gener:rlinl;'11c1, n•purts. I pace also Ittachvd a,upc of the frhech all that apply): ❑ Syste it set-up report: OAlan , histo, ' report. I eclmician Name rut : 0669-6 Signanue: (p ) __Samea P He k th Ccn/1-ic. No. Testing Company l\lamc: Oil Equipment Service _. Phmx No.: (2 __ _754 .1808 CiLNt-)i Pa,t• 1 m,c trvo