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ONITO G SYSTEM CERTIFICA j D For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Tit Toa Cal&f!aff; �gf regulations This form must be used to document testing and servicing of monitoring equipment.A separate ' oEjeport must be re ared for each•monitoring,systetn control Hanel by the technician who performs the work. A copy of thr-Orizi'.ix(u` fed to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regltiati g systems within 30 days of test date. A. General Infor ation Facility Name: Q CV Bldg.No.: Site Address: 2`� �t City:� �-zd Zip: Facility Contact Person: Contact Phone No.: -1021? Make/Model of Monitoring System: ` dl ca 100 0 Date of Testing/Servicing: 10q/06 B. Inventory of Equipment Tested/Certified Check theopppropriate boxes t4 indicatespecific a ui ment ins ected/serviced:. � Tank ID: Tank ID: 9 O.In-Tank Gauging Probe. Model: ' 1lru � A In-Tank Gauging Probe. Model; t U'Annular Space or Vault Sensor. Model ELS O Annular Space or Vault Sensor. Model: A Piping Sump/Trench Sensor(s). Model: (A 0 Piping Sump/Trench Sensor(s). Model: 4,3 O Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: — Mechanical Line Leak Detector. Model: ' WMechanical Line Leak Detector. Model: AMAA`ice O Electronic Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: _ JR Tank Overfill/High-Level Sensor. Model: AI'r,19 0 Tank Overfill',/High-Level Sensor. Model: �S ❑-Other(s2ecify equipment! a and model in Section E on Pae 2). ❑ Others eci equipment a and model in Section E on Pae 2 . Tank ID: ' Tank ID: In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: 91 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: �G 0 Piping Sump/Trench Sensor(s). Model: A S ❑ Piping Sump/Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model:. F.Mechanical Line Leak.Detector. Model: ►vt -sr O Mechanical Line Leak Detector. Model: _T ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: FaL Tank Overfill/High-Level Sensor. Model: �f` ❑ Tank Overfill',/High-Level Sensor. Model: ❑ Other's eci equipment a and model in Section E on Page 2). ❑ Others eci equipment a and model in Section E?PPa2 . Dispenser ID: Dispenser ID: Dispenser.Containment Sensor(s). Model' to (✓s _ 0 Dispenser Containment Sensor(s). Model: _ Shear Valve(s). Id Shear Valve(s). ❑ Dispenser Containment Floats and Chains . O Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model:. al A Dispenser Containment Sensor(s). Model: (it L 6 Shear Valve(s). X'Shear Valve(s). ❑ Dis enser Containment Floats and Chain (s). O Dispenser Containment Floats and Chains . Dispenser ID: Dispenser DD: __ _ O Dispenser Containment Sensor(s). Model: O Dispenser Containment Scnsor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chain (s). ❑ Dispenser Containment Floats 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 ejuiipment, For any eq pment able of generating such reports,I have also attached a copy of the repo eck al!that X�system set-up ! rm h story report Technician Name(print): \ a✓w-� / Signature: Certification No.: d-�,� -Li(P6 License.No.:_433159 Testing Company Name:_B.Z.Service Station Maintenance Phone No.:(_916_)_371-2380 Site Address:_630 Houston Street W. Sacramento,CA 95691 Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification