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19255517888 Main Fax GETTLER RYAN INC 04:41:46 p.m. 11-30-2007 2/4 MONITORING SYSTEM CE TI ICATION 5-37 T9" For U.ve B%.A1l.htr•ierlirrian.e Within the State of'Cetlifarttia atrthorits C'iteel:C7rcgrter6.7, Health and Safety Code•; Chapter l6, Division;, Title 23. Culifnrrricr(7a<!c aj"Re>ulutiern.c This form must he used to document testing and servicing of monitoring equipment. A separate certification or re)ort mU.I hei2re aced awl a., III IM4 11111M Muca m me 7 an --- system owner/operator. The owner/operator must Submit a copy of this form to the local agency,regulating UST systems within 30 clays of test date. ` A. General Information Facility Name: _ Bldg. No.:__ __ Site Address: City:. S 0Ul r0,/ Zi Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: ?ZS .orb v��rlv',Q /Ga+c7i Date of Testing/Servicing: W-4-U-1-0-7 B. Inventory of Equipment TesteWCertified Check the agerocriate boxes to indicate SC2121 a ui ment ins �cted/serviced: 1Tank ID: - 81 M4WX4- Tank ID: Qf U In-Tank Gauging Probe. Model: j tl U In-Tank Gauging Probe. Model.- Q t 7 390: J Annular Space or Vault Sensor. Model:ZQ4 310 -U � ❑ Annular Space or Vault Sensor. Model: U Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: �- U Fill Sump Sensor(s). Model: sk 3 ❑ Fill Sump Sensor(s). Model: ok (3 Mechanical Line Leak Detector. Model- U Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: U Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecif a ui meat type and model in Section E on Page 2). ❑ Other(s ecif a ui ment IZE and model in Section E on Pae 2). Tank ID: 7 seoef- Tank ID- U in-Tank Gauging Probe. Model ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: q Ll Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ?q�/�{M I2 3 ❑ Piping Sump/Trench Sensor(s). Model: U Fill Sump Sensor(s), Memel: 7 f cE3 t 0 3t ❑ 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: U Tank Overfill/High-Level Sensor. Model: _ F-er er(s ecif ui meat t and model in Section E on Page 2). ❑ Other(s ecif a ui mc:nt type and mode(in Section E on Page 2). ser ID: #Z- Dispenser ID: enser Containment Sensor(s). Model: 3 ❑ Dispenser Containment Sensor(s). Model:�-11-3y) ar Valve(s). ❑ Shear Valve(s). enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). ser ID: 3Lf Dispenser ID: enser Containment Sensor(s). Model: _`{�'?y �.t�j�'5 ❑ Dispenser Containment Sensor(s). Model: r Valve(s).. C1 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). er ID: � {� Dispenser ID: spenser Containment Sensor(s). Model:? 'j W ❑ Dispenser Containment Sensor(s). Model: L7 Shear Valve(s). U Shear Valve(s). ❑Dis user Containment Float(s)and Chain(s). U DisDenser Containment Floats)and Chain(s). -If the facility contains more tanks or dispensers,copy this form. Include infornruion 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 te.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 all that appf),): Sy:stern set-up Uarm history report Technician Name(print): j Signature:_ — -- -. 1�Certification No.: A�^� License. No.; -aV --....-- ---....._—._...._........ ---- r I-estiligCompany Naine: f/-1 fsyt.._—__...- ....._.._ PhoneNo.: SiteAddress: Page I of 3 n;trot Monitoringti}stem Certification