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07/28/2004 15:22 209-577-F040 BOYETT PETROLEUM PAGE 02/1 MONITORING SYSTEM CERTIFICATION For Use By A11.1urisdictions 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 sep4rate te this form must be provided fication or repo ust be the tank for eac� monitori to system cgntrot Dane) Ile red by the technician who performs the work. A copy 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 Bldg.No.: Facility Name: � � r`[-'�� Zip: � Site Address: Facility Contact Person: i�x: \fit Contact Phone No.: Make/Model of Monitoring System: L Date of Testing/Servicing: B. Inventory of Equipment',Tested/Certified Check the Approgrintr boxes to indicate s etifie equipment ins utcdlscrvietd: Tank IU. 'Tank ID: � - W Tank Gauging Probe. Model; n-Tank Gauging Probe. M o d c I 'Annular Spare or Vault Sensor. Model: U-Annular Space or Vault Sensor. Model• ❑ iping Sump/Trench Scnsor(s). Modcl: rf l la'Fiping Sump/'french Sensor(s). Model Dill Sump Sensor(s). Modcl: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: /"?� l lrMechanieal Line Leak Detector. Model.y ❑ Electronic Linc Leak Detector. Model: ❑ Electronic Linc Leak Detector. Model: 2rTank Overfill/Nigh-Levci Sensor. Model: 6 01�Tank Overfill/high-Level Sensor. Model: ❑ Other(specify c til ment a and model in Section E on PajZc 2). 1:1Other(specify equipment and model in Section E on Pago 2). To 1113: �� -' Tank ID: fGr �In-Tank Gauging l robe. Model: ❑ in-Tank Gaugin8 Probe_ Model• 2fAnnula.r Space or Vault Scnsor. Model: $" , '�►"' ❑ Annular acc or Vault Sensor. M . (iping Sump/Trench Scnsor(s). Model: SS ',� ❑ Piping Sump Sensor odcl: ❑ Fill Sump Scnsor(s), Model: ❑ Fill Sump Sensor(s). Model: D11V4cchanical Linc Lcak Dotoetor, Modcl;j�� ❑ Mechanical • eak Detector. ❑ Electronic Line Leak Detector. Moder 13 Elect ine Leak Detector. Model: 2'Tank Ovorfiill/�iigh-Level Sensor. Model: t- ❑ Tan Overfill/1-ligh-Level Scnsor, Model: ❑ Other s eci equipment t e and model in Section);on Pa c 2), ❑ Other(specifyui.ment c and model in Section E on Pa c 2), Ll Dis ser ID: -r�-� Dispenser ID: '� I�pcnscr Can#ammcnt Scnsor(s), Modcl: E❑ D• penser Containment Sensor(s). Modcl-. ❑ S ar Valve(s), d'Sh ar Valve(s). is.enser Containment Flouts and Chain(s). is enser Containment Float(s)and Chains . Dispenser ID: Dispenser ID: ❑ pis cn atnmcnL.Seosnl(5� Model: ❑ Dispense^r^'� m^^�eensor(s} Modcl: p�Sr�S-°nt ❑ Shear Valve(s). M Shear Valve(s). ❑ Dispenser Containment Floats and Chain (s). ❑ Dispenser Containment Floats and Chains . Dispenser Ib: Dispenser[D: ❑ Dispenser Contain Eln ,Dispenser Containment Sur s MOW: ; ❑ Shear Valve(s). ❑ Shear Valve(s)- ❑Dis enser Containment Float(s) and Chain (s). ❑ Dis enser Containment Floats and Chains . ^If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification -I certify that the equipment identified in this document was inspected/seryiced in accordance with the manufacturers' guidelines. Attached to this Certification is information (c.g. manufacturers' checklists necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equ nt. For any equip �Yea�abof ge crating such reports,[have also attached a copy of the report• Ch ck ate that apply): System set-up lye ort Technician Name(print):—71r—16k Signature: Certification No.: 0Q(-2 ��✓�� License,No.: Testing Company Name:` )&_1� `� l.S`fY) Phone No j_GD 171 I— bo 0 C) Site Address: Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification