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AFF' �A—TE$T 12097 r^'0112 P. 04 1`/ `J MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the state of California .authority Cited. Chapter 6.7, Health and Safely Code; Chapter 16, Division 3. Title 13, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment A separate certificatto! or report must be prepare for each monitoring system co(t�ol panel by the technician who perforans the work. A copy of this form rust be provided to the tank system ownerloperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within ;t days of test date. A. General Information Facility Name: wt.elFasy MART 13ldg.No.: Site Address: y 84t- 'ytU Ltn�t City: �S}ockt�o.A _Zip Facility Contact Person: M,'k e AL1' Contact Phone No.: oC o9 ) YQ -Bvv MakefModel of Monitoring System: dm;n f gC DEL la 00 , Date of Testing/Servicing:__S-I6"b3 B. Inventory of Equipment Tested/Certified Check thea ro date boxes to indicates ecifie¢ ul went inspected/serviced: Tank ID; 11AIL46A{CP Tank ID: PrC ✓ylty„ t ."In-Tank Gauging Probe. Model: #IT rG 0-In-Tank Gauging Probe. Model: ffi Y'fr r (,7Annular Space or Vault Sensor, Model: 2rAnnular Space or Vault Sensor. M del:lu- L W#2— (.Oiping Sump/Trench Scnsor(s). Model' ZrPiping Sump/Trench Sensor(s). M del: ex-L 5n"t _ 0 Fill Sump Sensor(s). Model: 13 Fill Sump Sensor(s). MSdcl: emechaaical Linc Leak Detector, Model: J"echanical Line Leak Detector. Madel: 0 Electronic Line Leak Detector. Model:_ 0 Electronic Line Leak Detector. Model! O Tank Overfill/tligh-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: ❑ Other(s oci ui stent t e and model in Section E on Pae 2), U Other(swify equipment t e and model in Section E on Page 2). Tank 10: Tan 0 In-Tank Gauging Probe. Model: 0 In-TankI probe. Model 0 Annular Space or Vault Sensor. Model: ❑ Annular Space or a4it Sensor. MJdel: _ 0 Piping Sump/ french Sensoi(s). el:_ Q Piping Sump!Trench r(s). Mddol: ❑ Fill Sump Scnsor(s). Model: 13 Pill Sump Sensor(s). MJdei: ❑ Mechanical Linc Lc ector. Model U Mechanical Line Leak Detector.�tldcly Ll Electronic Li A Detector. Model: D Electronic Line Leak Detector. Model: ❑ Tan r Ill/lligh.1 evel Sensor. Model: 0 Tank Overfill/High-Level Scnsor. Model: er s cciC ui meta t e and model in SeMion E on P e 2). 13Other s eoi ui ment a and modbl in Section E on Pa e Dispenser IIh Z Dispenser ID:_ 21 �f ¢ ( )Dispenser Containment Sensor(s). Model: ❑ Dispenser Contaimnent Sensor(s). Kidel: shear Vaive(s). JZKhear Valve(s). .@Dis enser Cotrtaimnent Float s)and Chains . $'Dis enser ContainmontTloat(s)and Chttin s). Dispenser ID: _ ` ^ nser iD: _ ❑ Dispenser Containment Sensor(s). Model: ❑ Disp Contalnmrnt Sensor(s). Model: 0 Shear Velvets,. ❑ $ hear Valve 0 Dts nser Containment Floats an ul(s . ❑ Dispenser Coutainm oat(s)and Chiun(s). Dispenser IU: Dispenser ID: '`�. Cl Dispenser Con ism ht Scrisor(s). Model:— ❑ Dispenser Containment Sensor(s). IvT6ae1: Q Shc e(s), Q Shear Valve(s). as enser Containment Floats and Chain (s). 0 Dispenser Containment Float(s)and Clifln(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 equipme t capable of generating such reports,1 have sten attached a copy of the report;(check ail that apply): ( )Svstem set-up ( Alarm history reporli Technician Name(print):_ LEE A. WU, _ MS Signature: Certification No.:—S-,-7-/ o., - b g ct License.No.: 03160 Testing Company Name:Stockton Service Station Eautpment Co Inc. Phone No.:W90464-8333 Site Address: 1414J l4a rh ,Date of Testing/Servicing: r//(� O _- Pape lof3 ___-