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19255517888 gain Fax GETTLER RYAN INC 7:07 p.m. 02-01-2007 3/9 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 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 monitorins 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 Infoorm/�tion Q t� Facility Name: K- N Foca FyJ A(Z cb # 2bJ 3 Bldg. No.: Site Address: 2k 2;` I sQt 4r Cv� City: 'o -4-C 3 Zip: Facility Contact Person: Contact Phone No.: ( Make/Model of Monitoring System: VCeA�V t2aot I TI S -'100 Date of Testing/Servicing: 1 /z y !� B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspect Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: Cl Piping Sump / Trench Sensor(s). Model: ,Fill Sump Sensor(s). Model: I j tl 3& 70 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID- T In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). O Fill Sump Sensor(s). ❑ Mechanical Line Leak Detecto Model: Model: Model: ❑ Electronic Line Leak D otedfor. Model: ❑ Tank Overfill/ - evel Sensor. Model: O Other (spqpW equipment type and model in Section E on Dia er ID: Dispenser Containment Sensor(s). Model: O Shear Valve(s). O Dispenser Containment Float(s) and Chaff Dispenser ID: ❑ Dispenser Containment S Model: O Shear Valve(s). ❑ Dispenser Contai nt Float(s) and Chain(: Tank ID: O In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor.Mod O Piping Sump / Trench Sensori, odea: Cl Fill Sump Sensor(s). Model: O Mechanical Line Le ector. Model: ❑ Electronic Li Detector. Model: O Tank O 11 High -Level Sensor. Model: O (specify equipment type and model in Section E on Page 2). nk ID• O In -Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: O Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line etector. Model: O Electrons Detector. Model: O T verfill / High -Level Sensor. Model: _other (specify equipment type and model in Section E on Page 2). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and C Dispenser ID: ❑ Dispenser Containment Se s). Model: ❑ Shear Valve(s). O Dispatser Conaffninent Float(s) and Chain(s). Dispenser ID: utspen O Dispe Containment Sensor(s). Model: O penser Containment Sensor(s). Model: ❑ S Valve(s). Shear Valve(s). isnenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). contains more tanks or dispensers, copy 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 Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a eoRy of the repo t; ((Check all that apply): *Sys em set ,Alarm histo report . , Technician Name (print): _ +� O, _% Signature- L ��. i 1 v0.y.� Certification No.: A 9 ®1 �3- ? License. No.: z 2 0 -4 g3 Testing Company Name: Cme'TTIef ' a-- Phone No.:(9Z,a Site Address: _—_ Date of Testing/Servicing: Page I of 3 03/01