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FROM : J.Schattar PHONE NO. : 2097442871 May. 27 2004 08:56AM P2 MONITORING SYSTEM CERTIFICATION lG'or Use B Al(.lv�rtsdictiors Within /he State o� ^4!{farnia Authority vied: Chapter 6, 7. tieolth and Sgfery Code, Choler 16, Dhlstour DFIle Z$' Calffavnia Goad of Regulations This foam rnusi be used to doetnrtent tcstfng andservicing of rnortitaring equina, .-;::r6rtt1ratrrn or !.'g= Tt *t be cl by the .tcchriiei= who performt the work, A appy a: this form must. be P%viitied m tato tank System oro�mcrJoparator- The owtterloperstor must. submit a cop!r of Ibis form to the local ftgency iegulwing USS' systems wi*dn 10 days of test date. - A. General Information sarvice Station No.: Factlity Name: A=O 5ito Address: _azZ- Ai .,C &,l ED fit, l City: Zip' Facility Contact Person, Contact Phone No.: Mal 2eModd ofMonitormg Syet,ern.: ( g -VDate of Tex +t@�Servico: 15—IS: - $. Inventory of Equipment Tested/Certified . Greek the ato fod3We cellae mt 0t inns serviced• tiara Tank ID: L�j' A�i-Tat>!c G`su8i;ng P,.�Ue: h+fodcl: Wank M! pYti-'zok Gauging Probe: MTodd: , WAWP—� Q�ruralar Sp= or vault Sensor; Modoi: Sven w+ Sertaar (s?: Model: i�'ipzrtg F�ro ❑lsmt, lm Spate or vault Sensor Motel: ❑Piping S�,tmprrrmch tensor (a): Mndel: ii ))l Sump Sensor (s): Model: d - pFifl Sump Sensor (s)' Made]: [� w OMcchadcal Lina Leak Deunter. Model: OMeahattical Linc Leal: Detector, Model: I»eak Dcloctor Model: REim maxtic Line Leak DuwcWr Model: q GF--jc=ottze Line CTank Cverfil/fl"io-level Stn=. Model; CTank OveMl,yff...jo-levd Smws Madel: ©oth¢r, S and rt,adei in Section E art 2 ❑Otbcr. and model in Section Eon Ne 2 Tack JD: 11 Tank tD: &A -Tank Qaauging - Model: Din -Teak Gvugixtg Probe: Madel: B�mtslar Spada or Vault Scnsnr: Mallei; :1 x n slw Space of Vaiflt Scm= Model: Mping %mpTrench Smwr (s): Model: ❑Piping Suriiprirench Sensor (s): Model: MP'iil Same Sensor (e); Modci: jz ©Fill Stung senwr (s): Mom! ❑M*char QW Lint Leak Detector, Model: aMechanical Line l.,ealt Detector, Model: _ lectaamic Line 'L care Detector Mallet: MBloctonic Linc Leak Ddector Model: LiTank Overflll/Mgk level Sert mi. Modal UTemk Ovetrfili Mfh-levol Son. : Model: and model in Sean E ou NiM 2 pocit Mg_ szd vwW in S�eetion P ort e 2 p00tthhcrr,,,�S Iit�ilicaw ID: Dkp=w iD �Ji6pettaaz Contairtmtnt Model; G� d -' C'Jisp®ser Centirattttnt Seusor(e): Model: M'Sltem VWva(s). erS hear Valvc(s). ContainttortL s snd Choat 3 ser Containment Floats and Clmia S .[3Diqmgw Dispenser M. Dispcstxr tD: kOspaaser Containment Sensors: Mcdtsl: ❑Dispenser Comamm mi knsor(s): Model: nl!% ar vaive(s). ❑ Shear ValWO- r Containment 82 and chain(s) 0T)Lvm=r Conisinsnrs t fleets and Cbham s Dlspeaw 11): 5!�Dispenser TD: ablgmW conmin=ut sown: Model: ser Coat dmttcnt Setwr(s),. Model: VrShW Valve(s). © Shear LQR�Mftr Contai=ent El ss and Chain s) DiMeser Coatein=tt and Chain(s) *Tf the facility corado s more tames or disp"w , copy this foma. Include information for cvery Cant and d1speum at tWz facititp. C. Ceirdfi ation - T certify ttmt the equipmnew tdenttfled It tato document vess inapecledisersiiced in sccordsncc watt the manutltstaren,' ZtddektvnsL Attadod to this Certification is info tier (e.g, neceasry to verity that osis rrifommhoa ie correct and a Plot Plan Onrft the layout of monitoring equipawet For any sgnlpm Brat capable of geaerft tach tenger,, 1 h"% 4106 attached au A& d&_ app(y)7 syscm aet-t GI y apo Tecvui}rNAm Prrtt): Signature; CeRifigatioa No. ooie —+ b"L % Limse No.. Tesdug Cov4xizN Name: Qmripion jywaa_ T Phdrtc No.: _(916) 927.1537 �oqn r n/i o�ror