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MONI&RING SYSTEM CERTIF 'TION i. For Use By All,Iurisdictions Within the State of Cali ornia ,authority Cited.-Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, C a Qgirl r This form must be used to document testing and servicing of monitoring equipment, '4 + ''• A s fi on a snort mil be o orad�x e c o �� m nti'n] anel 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 to agency regulating UST systems within 30 days of test date. SAN JOAQUIN COUNTY A. General Information ENVIRONMENTAL HEALTH DEPARTMENT Facility Name: A= Bldg.No.: —_ _ Site Address: City: -}'14n d0► 7ip� - -- Facility Contact Person: �"U1 Contact Phone No.: ( ) - MakePModel of Monitoring System: iso Date of Testing/Servicing: B. Inventory of Eciuipraent Tested/Certified Check thOproprime bones to indicate n ecitk t ui mettt Ins ected/serviced+ Tank W: b`Z Tank ID: ❑In Tank Ganging Probe. Model: ❑In-Tank Gtitrgiag Probe, Model: Annular Space or Vault Sensor. Model — Annular Space or Vault Sensor. Model: Piping Sump/Trench Serwr(s). Model: Piping Sump/Trench Sensor(s). Model: `` Fill Sump Sensor(s), Model: -'—32!2 _— Pill Sump scxuor(s). Model: y IDIMOianield Line Leek Detector. Model: \,,)A,g14-)2 6 m,:ohettical Line Leek Detector. Model: F tE ]Aeotronio Line Leak Detector. Medd: _T ❑Flect ut ii Linc Leak D dccbx. Model: fnk Overfill/IDigh-Lavd Sensor. Model: 1!1Ql Tank Overfill/High-Level Sensor. Model: her(specify cg111 mast type and model in Secton B on Page 2). ❑Other(Specify equipment typoand model ie Section E on'Pege 2), ID: � Tank ID: Tank Gauging Probe- Model: ❑In-Tank Gaugmg Probe.nulsr Space or Vault Sensor. Model: (p1 ❑Annular Space or Vault Sensor. Model: Piping Sump I Trench Sensor(s). Model: __ El Piping Sump/'french Sensor(s). Modei: Pill Saul;+Scm"T(s). Model: -- ❑Ell)Sump Scnsfx(s)- Model: mmhmicel Lias Leak Detector. Model: {`L L [�Mechanical Line Leak Lletector. Model: ❑'Electronic Lino Leak Detector. Model: ❑Electronic line Leah Detector. Model: Tank Overfill/1-Ligh-Level.Sensor. Mo&l-. I I ❑Tank Overfill/High-Iavcl Sensor. Model: Other(specify equipmeitt-type and model in$ection E on Page 2). [].Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑Dispenser Containmcnt Scnsor(s). Model: ❑Diepenser Containment Seosar(s}. ModcL [j Shear Valve(s). �Shear Valvc(s). ❑Dispenser Containmont Float(s)sod Chain(s). Dispenser Containment Float(s)and Chain(s)- Dispenser ID: Disptnser ID: 0 Dispenser Containment Sensor(s). Model: — ❑Dispenser Caattninntomt Sensors). Model: ❑Sheer Valve(s). ❑Shear Veave(s)- 0 Dispenser Containmomt Floats)and Chain(s). ©Dispetw Contaminant Float(s)and Chein(s). 1DlspoaSer ID: Dispenser ID: Fj Disimmm Containment Samm(s). Model: —7AL-�)Z ❑Dispenser Caataintnent Sensor(s). Madel: —5Z)15, El Shear valve(s). — ❑Shear Valve(s). ©otcspenscr C.Ontwnencot Ftoat(s)and Cham(s). ❑Dispenser Containment FMaa(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification.1 certify that the equipment identified In this document was inspected/serviced in accordance with the manufacturers' guideliines. Attaebed to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a SiWELfi t Pian Showing the layout of monitoring muipment, For any egt>fi went capable of generatin such reports, have also attached s copy of the report;(check all that appty): System set-up Alarm history report�y\j Technician Name(print);_Tony Fontana Signature: 1N-5 Certifica, tioa1k,-. V.R.A_23686 ICC 5289227-UT License,No. A.8462W'— Testing 462 Testing Company Name: U.S.T.C Me TeSting Inc. Phone:.No.:(209)' *4489 Testing Company Address: P.O. Box 580 Ceres, CA 95307 Dat#OOfTOsthY,gJ Iarviow.,mss' !1N{►36 ]I6 WWW.rnldou.ory °^