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' 'O- 2-06:12:00PM;Sacramento EMC <br />i <br />;916 9252215 # 11 <br />-MONITORING SYSTEM CERTIIFICATION <br />For Use by all Jurisdictions Within the State of California <br />Authrrity Cited: Chapter E.'%, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations <br />This form must be used to document testing and servicing of monitoring equipment. A sgarate certification or report must be prepared for each monitoring system <br />control panel by the technician who performs the work. A copy ofthis form must be provided to the tank system owner/operator. (The owner/operator must submit a copy <br />.i_ <br />f this fora( to the iocai agency regulating UST systems withing 30 days of test date. <br />Fac;1 iry Nar ,e <br />7/11 <br />B'dg No. <br />li 19976 <br />Site Addrese: <br />1.394 i4orth -Iain Street <br />City <br />Manteca <br />zip 9533L <br />Facilit} Contact Person: <br />X Fill Sump Seasor(s) i H <br />Contact Phone Na: <br />209-239-3252 <br />Y1eFe vlodel of Monitoring System: <br />1-1 <br />Date of Testing/Servicing: <br />08-16-06 <br />B. taorrilery of L' laipmert Tested/C:er hied! <br />3i�AZS1811�..497�PS.Lt1.ln^�.te sne�n. eau,ntg <br />; ! IC: T?-LrtLe+de•' <br />t- <br />In -Tank Ganging Probe B <br />X Tank Annular Space or Vault Sensor A <br />, - <br />Model <br />794380-302 <br />Tank ID: T5 - Premium <br />In -Tanis Gauging Prix B <br />X Tank Annutas Space or Veulr Sensor A <br />yy 1 <br />i Model ! <br />794380-362 <br />k Piping Sump 1 Trend Sensors) P <br />794380-208 <br />X <br />Piping Sump / Trench Sensor(s) <br />P <br />79438(1-2 )13 f <br />X Fill Sump Seasor(s) i H <br />794380.208 <br />X <br />Fill Stn» p Scusor(s) <br />1-1 <br />794380-238 <br />Mechanical Lane . : r. bete=tar td <br />Mxhaiieal L.lne Zeck Detector <br />i M, <br />i Electronic Line Leak Detector <br />E <br />Electronic Line Leal; Dete:ctcr <br />1 E <br />Tank Overfill/High-level Sensor <br />T <br />Tank C}verflUrIigh-(.vel Senior <br />T <br />I� Pi�ptnS'Sump Se r_ca: C4ctaic_rrcnt Sensor <br />t K <br />Piping Stump Seconcary Containment Seiror <br />K <br />' :i'1 SUM-, !.c-mir.-ren^ Sensor <br />K <br />Fill Sump Secondary Contiimoent Seasor <br />K <br />Prrdxt t -re Se; oris y r'o tainr7ent Sa.nsor W <br />Purdue* Lite Seconcary Con°aiwnent Sensor W <br />Vere. Lire Secondary Containment Sensor W <br />Vent Lane Secondary Contairment Sensor <br />Other (speci yequiomeni typo end n..odc! in Sec'icr E on ?acc 2) <br />Other (speciF equipneot type and model M Section E on Page 2) <br />Tank M: T3 <br />Model <br />Vent Stump: <br />Mcdel <br />to B <br />Vent Piping Std S-msor F <br />%rnulcr S?nee or Vacit Sen -Or ° A <br />Vent Sump Seconda-y Contimment Senso- i K <br />!. <br />t riping Stnnp/ Trench Sensor(s) <br />1 <br />t�..� !`.Il Surra• Soso"S' I H <br />Y - ??ectanical Line Leak lletertOr M <br />r.(e :r r.le Lina _.'alt ie:ector E <br />Vapor Recover/ Line <br />Vapor Rentm Secondary ContainmentW <br />i <br />Tank OverEll.'High-level Sensor T <br />r ipiag Sump Secondary Contai-nrncnt Sensor K <br />Nl Sump Secondar, C oulaim ;e::t Sensor K <br />2rodtto `,i�cSe:ordzr,+Ccn'an-entSonscr W <br />1 <br />! i <br />g1- <br />Veni C.;ne S�rondar� Containment Sersor '� W <br />Other (speci E; equip„ent type aid model;, Section 2 ca "age 2) <br />C. Certification -1 certify that the egaipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to <br />this Ccrifceion is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layot:t of <br />nos+ir; rins•, e^ui- e ti For any equipment capable of generating such reports, I have also attached a copy o`the (check all that pclyl: <br />;Y System set-up report (attached) X Alarm history report (attached) <br />t <br />Tec'nniciatt Name (print): Brian Roth Signature: <br />Certificate: 006054370 Contractors License No.: 502'$77 <br />Testing Company Nalre: Sacr-amento Equipment -Maintenance Company, Inc. Phone No. 916-925-2716 Work Order 4 122462 <br />03101 countyh0000f/state/1-monitonngcert.w)d Page l of 5 <br />