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r�vF ` MONi. 01-UNG SYSTEM CERTIF1,%.AT'ION For Use Btu.Ill Juriseliclions 1 71hin the,Stale of Carli f(rrnia ' Anthorily Cited: Chapter 6.7, fleallh and Safely Code; Chapter 16, Division 3, Tille 23, California CO(le of ftukrlions 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 copy of this form to the local agency regulating UST systems within 30'days of test date. A. General Information Facility Name: M4 9-nae_ - ST 5,Ee Vle-es Bldg.No.: Site Address: 3505 /y4VY D,�_ City: !3roc&-ro"i Zip: Facility Contact Person: UWA AW Contact Phone No.: ( _U 7 ) Make/Model of Monitoring System: Ilowy 'r5 /bo F Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific c ui ment ins ected/serviced: Tank ID: 7 U Tank ID: ❑ In-Tank Gauging Probe, Model: ❑ In-Tank Gauging Probe. Model: QLAnnular Space or Vault Sensor. Model: 6/5 ❑ Annular Space or Vault Sensor. Model: Rk Piping Sump/Trench Sensor(s). Model: L[e 5 ❑ 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: LS ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment tye and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae ). Tank ID: 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(s iecify e uipment type and model in Section E on Page 2). ❑ Other(s�eci �equipment type and model in Section E o ge 2). Dispenser 1D: 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). Dispenser ID: Dispenser ID: t ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis 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( . ❑ Dispenser Containment Float(s)and Chain(s). '°If the facility contains more tanks or dispensers,copy this form. Incl u ifornnation for every tank and dispenser at the facility. 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 alllhal apply): �ystem set-up .Alarm history report Technician Name(print):—�iN€�VmC► Signature: fi;Qc , � Certification No.: SCC 526 Certi ��2�3 License. Testing Company Name:—A& f4 - —1 '�s r Phone No.:GQo )Thh/ - in&z Site Address: 36c),5 1444 3W - Date of Testing/Servicing: �o If-5- Page LSPage I of 3 � Monitoring System Certification IKt C D. Results of Testing/Servicing u uuJUL 0 2 2007 SAN JOAQIJIN COUNTY ENVIRONMENTAL HEALTH DEPT.