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19255517888 Main Fax GETTLER RYAN INC 12 08:17 p.m. 01-11-2007 2111 711.3 MONITORING SYSTEM CLINFICATION For Use By All Jurisdictions Within the State of California Authority Cited. Chapter 6, 7, 1lealth and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: __I4_rtA2__ - Bldg. No.:a jopl� Site Address: 3 1 4 a ,'Gp rnC _1A__Xt1t_._ City: Sjnc f7D Zip: Facility Contact Person: _ Contact Phone No.: Make/Model of Monitoring System: 'rf-S r 3SDate of Testing/Servicing: x/20 /06 B. Inventory of Equipment Tested/Certified r -h....,, N.o t,- m indir2tr aneritir eouinment iasntcted/serviced: Tank ID: F17:1 er's t'+1 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: 79 13 RPO --;.?3 ❑ Piping Sump / Trench Sensor(s). Model: ❑ 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: 1) Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank rD- ❑ 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: ❑ Fill Sump Scnsot(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: O Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: _ XDispenser Containment Sensor(s). Model: Z g qj m – 3.23 . ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). ❑ Shear Valvc(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: _ Dispenser ID: ❑ Dispenser Containment Sensor(s). Madel: _ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model ❑ Shear Valve(s). ❑ Shcar Valve(s). ❑Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). 'It the facility contains more tanKs or otspensers, copy mis roan. mcroue uuurmauun rur every mnK a,iu atspenser at the iacuity. 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 generating such reports, I have also attachA a copy of the report; (check all that apply): ❑ Syst t -up Ll Alarm history report Technician Name (print): (�ANfJ,Y R20�_w Signature: /lis Certification No.: �} 2 / ? / _ License. No.: Testing Company Name: C=M}Aier Gx4h f in C. Phone No.,.( 9.2 S_ ) S—S/ Y 7 7 7 Site Address: _ Date of Testing/Servicing: 0-12o l td 6 Page 1 of 3 03/01