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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Califomia 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 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 a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility N COUNTRY CLUB FOOD AND FUEL Bldg. No.: Site AddAdd racc• 1856 COUNTRY CLUB City: STOCKTON Zip: Facility Contact Parcnn- PHIL Contact Phone No.: (209) Make/Model of Monitoring System: OMNTEC OEL 8000 Date of Testing/Servicing: 8127/2009 B. Inventory of Equipment Tested/Certified Cheek the annronriatp boxes to indicate specific eauinment irisDected/serviced: Tank ID: 87 Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor, Model: OPTICAL ® Annular Space or Vault Sensor. Model: OPTICAL ® Piping Sump / Trench Sensor(s), Model: ELS ® Piping Sump / Trench Sensor(s). Model: ELS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: RJ FX1V ® Mechanical Line Leak Detector. Model: RJ FX1V ❑ Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). 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 (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: DispenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Roat(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). `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/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, t have also attached a copy of the report; (check aU that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Gf----- Certification No.: 834976 License No: 5273934 -UT 08-1740 OTTL Testing Company Name. AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: __. 416 _ __STREET GALT, CA 95632 Date of Testing/Servicing: 08-27-09 Monitoring System Certification Page 1 of 4 2/21/07 9T00/60001E 9TTO VVL 60Z XM TV:TT 60OZ/ZO/TT