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MONITORING SYSTEM FICA For Use By All briAcfioris Mthin the*Rate gf Cal&rnia Authority Cited:Chapter 6.7,Health Code;Chapter 16,Davision 3, rifle 23, Cal#brnia Code of Regulations This form must be used to document testing and servicing of monitoring equipment.,& separate ce ' taboo or report stbe ar+erj for each monitoring system c 1 Ron by the technician who performs the work. A copy of this form must be providedto the twik 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 Faciht Name Bp pRQQUCT CON1PAtdY Zt3' Service Station No.: 12133 „ — -_...._._....__..._-__.. Site Address: 2908 BENJAMIN HOLT DR Cites: ; STOCKTON 1 Zip_ 195247 FncslityContact Pen on ... ... Contact Phone No Zdr1 `het-� 35 odelofMotutonxagSystexn B.. Inventory of Equipment Tested/Certified Check do riate boxes to Wicate specific equipment bwpewctedfse:vi sed: To nk M:_ Teak M: Ir>rTa*Gt gFrobe _...._.__.- Model: 8 t1D- ic-7 In-Tw*g . Probe: Model �� 0H_117" erSpaceox.VaultSensor: 1 Model_ '. p- O O Armula_§paceorVault Sensor Model: o S_ _ renehSer�sar e) Model�1rict >- 8 irgS renchSensor(s� Mod el:M ode• o1jASE eModal schanical l ine Leak Detector. Model: ' echanicalline Leak Detector. Model:ectronic Line Lea1t Detector A6ode1: L�"'> onic Line Leek DetectorModel t��-S> l C3v_arSl m -level Sensor: Model- 7 9 6 o 9 S or,r exalt Ov d _gbAevel Sensor: Model: ! 1.3co dex;S ec' a ui .t e and model in Section E on Pa e 2 Othe Sec° a tai .t e and model in Section E on PaT ID: Tank ID: _TankNuguigProbe ___._.____ odeL cr - r Ia.TankOa gProbe:__..___.__ oriel: ___ arSpnce arVaultSensax: _IVlodel ZO AnnulorSpace orYsultSensor Model: §m,__§ m,_ ff renchSensor(s): Model n { - 6 ,�il?ir�S ._ renchSensor(s): Model i1lSumpSensar(s). __ __.__. . :..ModeL r -Zo Fill Saaxr�Sensar(s� Modal. _echwAcal Line Leek Detector. Model: chanicalLine Leek Detector.. _Model: Vie- - _.Line Leak Detactor- Model: Electronic Line Leak Detector __Model: enkOverfill/ki' -levelSexasor Model '?9 csc 9s' ®r ankOv IevelSensor Madel: ec' e ' .t a and model in Section E on P e t S ec!'k a e and model in Section E on Page t Dispenser ID; enset ContainmentSensors: ! Model yy c7g, onset Containmentou Sheer Y elv s eraser Containment Flo gUs andCh!irgo I} eraser Containment Flo! s and Ch ' s ~' - DispenserlD `7` F, Dis onsetiD: �penserContainmentSensors Model `S�rJ.+{, -Z� • T3ionset ContasrarnentSensoss :__ Model:(1)7C+CSicr'Z Shear 6elve(s) Shear Yslve(s). phis sneer Containment Flo s and Chain(!) Des eraser Co ent Flo s and Chia eraser ID: anser ID DispexisetConentSens ors Model: D:s enser Containment Sens s : model. Shear Vel_v_e(s} __-- -----.____. .._ .. _,. _ ShearYalva(s --_ _ 6 Dis enser C ent Flo s and Ch ' s Dis enser Containment Flo s and Ch ' s *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser tit this facility. C. Certification-I certW that the equipment jjmtuw in dds doement was inVecteNserviced is accopbmce with the AttwhrA to this Certification is imbrawtiolft(e.g.aaa lL m'c ts)necessary to verify that dkis inbrmation is cornet and a Plot Plan skewing the layout of monitoring equipRaemt. For any capable of generating such reports,I knedw attrehei a copy of the me rt�(check ati �a_ Systext set-vv 3� Pr _. °� . TechmcsaName(Print): r4.)- CestificationNo,: LicenseNo.: TestingCo,mpanyName: TAIT ENVIRONME14TALSYSTEMS Phone No.: (714)5604222