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E MONI16UNG SYSTEM CERTIF&TION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23'California-: ppof(gull ti ns This form must be used to document testing and servicing of monitoring equipment.A se arate certification otic ust be re ared for each monitoring system control panel by the technician who performs the work. A copyrytt¢¢�1 e�pprovided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regul7tinj 1:6flems within 30 days of test date. A. General Information Facility Name: My /A t-n A4a r 1' Bldg.No.: Site Address: +k Wilsu n WA City: 5I-oeActoyl zip 9r Facility Contact Person: I_e 1 Contact Phone No.: ( Make/Model of Monitoring System: -'nitlm T•5 t UO( Date of Testing/Servicing: -7-P-03 B. Inventory of Equipment Tested/Certified Check the a ro nate boxes to indicatespecific equipment inspected/serviced. Tank ID: f.� Tank ID: r`Cwl'U 01 /�In-Tank Gauging Probe. Model: 21n-Tank Gauging Probe. Model: (/)Annular Space or Vault Sensor. Model:_ t✓'��_ _ 2 Annular Space or Vault Sensor. Model: Z� (•Piping Sump/Trench Sensor(s). Model: V(,S jYPiping Sump/Trench Sensor(s). Model:_ LS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model:6. P7L I V )d Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ an Ovell/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: _ ❑ Other�s2ecia a ui ment a and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: U 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: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify a ui ment Ue and model in Section E on Pae 2). ❑ Others eci a ui ment Ue and model in Section E on Page 2). Dispenser ID: V& Dispenser ID: ( )Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: j]'Shear Valve(s). a Shear Valve(s). lirDislienser Containment Floats and Chains . H'Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain (s). ❑ Dis enser Containment Floats and Chains . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model:_ ❑ Shear Valve(s). ElShear Valve(s). ❑Dis enser Containment Floats and Chain (s). ❑ Dis enser Containment Floats and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. 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 information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of genera ing such reports,I have also attached a copy of the report;(check all that apply): k,)-System set-up (X Iarm history repo Technician Name(print): LEE A.WILLIAMS Signature: L '/ Certification No.: ,� / 109-0q'l License.No.: 03160 Testing Company Name: Stockton Service Station Equipment Co.,Inc. Phone No.:(209)464-8333 Site Address: Date of Testing/Servicing: 7- `0 7i ORIGINAL MAILED TO: San Joaquin County Page I of 3 Environmental Health Div. 03/01 Monitoring System Certification Attn: Dennis Catenyag 304 E.Weber St.,3`d Floor Stockton, CA 95202