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MONITORING SYSTEM CERTIFICATION <br /> or Use By All Jurisdictions Vrhin the Slate of California <br /> Aathorfry Cited:Chapter6.7.Health and Sgfery Code.,Chapter 16, Division 3,Title 23. Californio Code ofRegaimiaaa <br /> This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be Prepared <br /> for each monitoring system control Panel by the technician who performs the work. A copy of this form most be provided to the tank <br /> system ownerloperator. The ownedoperator trout submit a copy of this form to the local agency regulating UST systems within 30 <br /> days of test date. <br /> A. General information ------ <br /> Facility Name: dg.No.: <br /> TIME OIL 04-167 <br /> Site Address: 1434 W- YOSEMITE AVE. _ Zip: <br /> Facility Contact Person: MANTECA, CA 95336 <br /> Make/Model of Monitoring System: Date of TcAm9fSerwici.W' _1 12-1 D Z <br /> B. Inventory of Equipment Tested/Certified <br /> (�kt>u ta�mi <br /> Tank M. ) <'. Tank ID_ <br /> t�(7>tTaak GaagiaBProhe ModcL -7 1, cl_bt-TmL Crairgmg Probe. Model <br /> 0 Annular Spats of Vault Senior_ Madel: _Ij !�Aalli}St Spare or Vmdt Sensor: Model: <br /> o"d.Pimng Sm®p/7readaSmsm(s} Madel: �P;pigg Siwp/raarh Smsot{s} Model: les <br /> 7 Fill Sump Smvor(s)_ Model: - a Fill Sump Seas a(s)- Mold: <br /> ;iT Masha nerd line Irak Detector. Madel: eel 0 Medona l Lime I&&Deu!aoe Madel: <br /> 4©ecuanic Live leak Detector. Model: U 5ccuoun:line leak Dcua Moder: <br /> D Taak Overtill i Ilgh-level Senor. Model: CI Tact OvuM l Hign-Level Sensor. Model: <br /> O other(Specify and model in Sect:m E on Page 2). ❑Other(zpccx6r equipment type and model in Suction E on PW 2). <br /> Tank m = Tank ID: <br /> lr hi-Taut CratlgiagPmbr- Made): -7'7 Z. ❑In-TankOmpiag Probe. Model: <br /> kl Anu lx Space or Vawh Scosor. MmhtZo ❑Anoo�Specs err Vaoh Smvur. Medd <br /> �.Piping Sump l Tretrh Seasods} Had —t Q PipmgSomp1Tr=ch Sencm(s} Model: <br /> Fill Sump Seasot(s). Medd O fill Sapp Seusm(s)- Model <br /> fi@Mechanlcal Lie leak Dmum Modet S-f - u1LD 0 Mecbaaical lice leak Dcww Model: <br /> ❑Plcuronic Line LeakDepxtor. Modem D Ylecuomclinel=kDerecrm: Madel <br /> O Tank Orzfill I lEgh-Eifel Sensor. Model- ❑Tank Ove fill l l&gb-Leret Senior. Model <br /> U Odor and model in Section E on Pate 2), D Odes( ' can mode)ode)in Section E on Pare 2). <br /> DLspenserID - Z 2) rID: - <br /> ❑ Model: .7 DiipciurrContliamentSmm(s). Mudd: <br /> el Sb=Valvc(s)- t rsbnarYahe(s} <br /> 1� C.onmairemmt FIoat(s and Chaia(s} - ComaopmmtAows)and C3ai(:)- <br /> DispeasecI4 - DMD i <br /> P Dispeusa C®tain ne u Semm(s). Modek- ❑Dispmsa Lloarammem Smsta(s). Model <br /> a Shear vzde*s} - 9.%M ValwIXs). <br /> Cwtammmt s and Chain(sl MDispemor Containment F7ou(s)and Chain(s). <br /> SID: SID= <br /> ❑Dispenser Contaimem Sensor(s). ModL DDispmv'Coaoummm[Seosm(a)- Model <br /> Shear Va)rx(sl ❑Shta<Vahc(s), <br /> ser contb®mt FiDwe end Chmu(s). I Ck DtkP=W C®tainmmt Flows)and Chxin(s). <br /> *If the faulty emutadus moa tanks or d8spatsers,copy this toren Include information for every link and dispeaw at role facility- <br /> C. Celtictatitin-I ratify,that tic equipmeut idm6lied in this lora ent aas v pedtft dad I.accordance with the ..m1duct"Im, <br /> gmddiam. Attached to this CettiScatim Is mformatlon (eg-mss'droddW aereamry to ve,*that this information is <br /> mrreY and a Plat Plan sbvwwg the lay+m ofmmfto®g equiIanieWt For anp equqme'rt ogabte cf gmembn molt reports,l bave also <br /> attached a copy of the Signauae• 13 <br /> Technician Name(hest): ^' 77 <br /> Certification <br /> port <br /> No.: oX.,fc-ae -xof -7�37 LAcenn.No.: <br /> Testing Company Name: �,,//�rl K`TE K Phone No.:(tLL) <br /> Site Address: I l j 3r.l W, Vz)fie 1)-)i 4 e AVe 1q"IPJ n4 e cit.- lime of Testiagaarviciag: <br /> Page I eta o3rot <br /> Monitoring System Certification <br />