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MOORING SYSTEM CERTIICATION 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 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 i [{�MT form to the local agency regulating UST systems within 30 days of test date. �b �h L`L��LJ��CC A. General Information . U V 9 Facility Name: &,A5 g/ 44" MAR — 5 2008 Bldg.No.: � Site Address: 3cf 3'/�/�f1�y a D ENVIRONMENT HEALTH City: Sloe_ie 0/' C Zip S'S' Facility Contact Person: 0144�r pF /SERVICES Contact Phone No.: Z.0% �'rG Z Make/Model of Monitoring System: VQ TLS Ste`" Date of Testing/Servicing: Z — 7Or -DP B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/sen iced: Tank ID: #1 Tank ID: a In-Tank Ganging 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 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(s ecifr equipment t) e and model in Section E on Page 2). ❑ Other(speciL e ui ment ty e and model in Section E on Pae 2). Tank ID: #2 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: _ ❑ 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 equipment type and model in Section E on Page 2). ❑ Other(specify e ui ment a and model in Section E on Pae 2). Dispenser ID: /4&,o Z Dispenser ID: p,),'Dispenser Containment Sensor(s). Model: V 12. -Z0Ff ❑ 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). ❑ 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). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). •If the facility contains more tanks or aispensers,copy this form. inciudc iufounation for every tank pnd dispenser at tho facilit;. 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 attached a copy of the report; (check all that apply): ( )System set-up ( )Alarm history report Technician Name(print): fQ/` /lfaG64,4ge > Signature.: /eG 62507 0-4r CAL 4- c 3agic9�" A 6�/a�K�� Certification No.: t//1 A Z 79 q 5 License No.: Testing Company Name: STOCKTON SERVICE STATION EQUIPMENT CO. INC. Phone No 209-464-8333 Site Address: Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification