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s <br /> MONITORING SYSTEM CERTIFICATION <br /> For Uss BY All Jurialtctions Rhin the Mate®f California <br /> Cited:Chapfsr 6.7, HeAlth and Cods;Chcoor 16,Division 3, ?Ytle 23, California Cods of Regulations <br /> 'his form must be used to document testing and servicing of monitoting equipment.,6 iarnt cation gz reportn�,st ba_ end <br /> or each monitoreRg ys •m cont.o1 gwgi by the technician who performs the work. A copy of this form must be provided to the tank <br /> ;ystem ownerfoperator. The ownerfoperator must submit a copy of this form to the local agency regWating UST systems within 30 <br /> lays of test date. <br /> X. General Info rmatio n <br /> _ _...�. _ __._ _._._....... ... _.__. .____..._. . <br /> acalst Nnme O PRODUff_C031dPANY T --` T- _._ .._...... <br /> 2093 _� <br /> Situate Stattan Na.: : <br /> site AddYess 3425 TRACY BLVD ___...___.___.W <br /> City: ; TRACY ; 95376 3 <br /> QacilityContactParson: Cont ctPhotaeNo.: <br /> Mak _.. ..___.... ___..___.___.. ...__.�_____.. _ <br /> .._.__......odalofMonit S�s4emDateofTo erv_ice: <br /> B. Inventory of Eqv ipment Tests d/C ed <br /> Check taerials boxes to e <br /> Tank ID: Tarek M: <br /> in' <br /> ' Probe: Modok nTarakGou Probe Model <br /> rSpoce-orYaultSensor: ; Model: raraularpace orVauttSensor Model: <br /> ;gSumrenchSensor�s, Model S fTrenchSensor '_Model: <br /> __— -__..._ -. <br /> Sensor Mo___. <br /> ills Sansor�s �___ _..... Model : r31S s <br /> Mechanical Line Leak Detector, Model: ' ech ' al Line Leak Detector. Model- <br /> ecttvnic Line Leak Detector Modal ctronic Line Leak Detector _ Model: <br /> ankOVerfilllI3ileeiSeasor _' 1+RodoL_; L ! anicOV _ levelSensor: ! Model <br /> theSpecify o e and model m Section Eon P e 3 then �so a ui Me and model in Section Eon P -e 2 <br /> Tank ID: Tank ID: <br /> [Anr <br /> nkGn robe: Model n•T Probe: Modal: <br /> laxSpace orVnultSensor: Model: ! zanutar�nce arVaultSerasoz Model: <br /> renchSon!gx0) Model: iragS fTrenchSensor�s3� Modalmponsor�s) _ model u illSumpSensarModel:anicalLineLeekDetector Model: ' achanicalLineLeakDetector. Model: <br /> onic Line Leek Detector Model: ctronic lane LookDateOY _ikVelSmssar --MOdel .7100% ankC3va ifh levalS or Model <br /> S <br /> ecify e e and model in Section E on P e 2 er, ec' a Ui . e mad model in Section E on P e 2 <br /> Dispensex <br /> ID: sneer ID: <br /> onserCn ent ensors Model _ enserContainment enso s : Model <br /> ShoarVnlve s ShaarValve(s). <br /> Die onset Containment Flocs and C s is eraser Containment Flo s and <br /> DispensOr ID: _ enser_1D:__ <br /> DssenserC en Sensors: ' Model: is enserContainmentSens s : Model: <br /> . .....� ._.._._._.... off.) _.,_....,_ <br /> She�Valve(s)._....._...__._. .. .........Die eraser C ent Flo" s ani Ch ° s is eraser Containment Flo s and Ch ' s <br /> eraser ID: on lD: <br /> �DispensorCa _-. sensors^ ;_Model: =SZ <br /> pentSax3so s)_ _Model_ <br /> Shear Valve(s). eraser C ent F1on s and Ch ' s <br /> If the fecility contains more tanks or dispensers,copy this form. Include infoaation for evety tank and dispenser at this facility. <br /> C. Ce cation-I cert*tkat the tl mea!identiftl is this bewmatwasd/nnind in moidowe with the manubtWoW <br /> gvIdelbos. Attached to this Certifikotion is ear'checklists)necessary to verify that tbis ia6=xdm is <br /> conec <br /> _M—e ' _ s r..' -_ __ ...__ _O' _ <br /> ane fuc]i arts,I <br /> !and:Plot Pl:n: f 5 Foran . ment AU of t hwaW <br /> TechnacaanNem�Q_ �, 04.4—�u4 :-_:,...__ <br /> -- - _ . - .. <br /> Certai"xcation Na.: License No.: <br /> Tes CampmnyName: TAIT FIMRONMENTALS " Phone No.: Cfl5ki-8222 <br /> Page I of 3 03/01 <br />