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Work Order: 2256117 is 0 Monitoring System Equipment Certification For Use By A11 Jurfsdiodorls within,7he State of California Authority Cited.- Chapter 6.7, Heaith and Safety Code; Chapter 16, Division 3, 7Ytle 23, California Code of Regulations This form must be used to document testing and .servicing of tnonitoring equipment. A 2Marate certification oc rt m b . nngmd for each M211 to 'nn system con o anel' p re — � 1 �— by technician wife performs the work. A copy of this form must be provided to the tank system ovmer/operator. The owner/uperator must submit a. copy of this form to the local within 30 days oftest date. �7 regulating UST system A. "Genera! Information Facility Name: j.,s.,-U Bldg. No.. f_ ?(1114 Site Address; _3')l�rn!(�� — city- Ll�, Zip: `%17 7 (v Facility Contact Person:. Contact Phone No.: L,e Makellafodel ofbionitoring System:S — 3 Date of Testing/Sarvicing: 3 - M -11'Y B. Itlrentory of Equipment TestiWCeriif:ed Check the approirdite bonen to indicate nwerhe enal.e...4........a.__ -- Tank JD. Q In - Tank Gauging Probe. Model: Tank 1D• L. Yq O Annular Spam or Vault Sensor. Model: D In - Tank 0aughag robe. Model; rd `16ipiog Sump 1 Trench Sensor (s). Model: Q Annular Spam or Vault Sensor. Model: D Fill Sump Sensor (s). _ 7ot Mcdel: "Pig Sump \ Tranch Sensor (a). Mod& t C y D Mechanical Liao LakDetecter. Model: 0 Fill Sump Sensor (51 Modes: 0 U*cb0a1c Liao Lcak Deteceor. Model: 0 Mechanical Line leak Detector. Model: D Tank overfill I DDigh-Level Sensor. Madel Q Electronic Line Leak Detector. Model: Q Other (sp-* equipmcut type and model in Seetim B' on Pogo 21 Q Tank Overfill 1 High -Level Sensor. Modal. Q Other ( specify equipment type and medal in Section Eon page 21 Tank LD�3 k I Q In - Tank Ctaugmg probe Medd Tank IA• Q ular Space o Vault Sensor. Model: _ 0 in - Tank Cnughrg Probe Model: "ping Sump 4 Trouoh Sensor (s) Model z OA O Aynular space or Vault Sensor, Model; 0 Fill Sump Sensor (s). . Model: ---�— sf�r *x Sump 1 Trench Sduor (s) Model: T p 0 Mechanical Line Lesk Detector. Medal. 13 Fill Sump Sensor (s) Model: D Electronic Line Leak Ddtactor. Model: D Mechaaica! Line Leak Detector, Model: 0 Tank Overfill t High -Level Sensor. Model' 0 Electronic Line Lai Detector. Madel: Q 01her ( specify equipment type and model in Section E on Page 2). 0 Tank Ovww 1 }ish.ya el Sensor. Model: Dien....... m. Il , r' Q Other (specify equipaent typo cadmodel _ _ ie Section E on Page 2}. Q D" ser Conttinnreat Sensor (s) Model; Chain (s). hear Vdve (a} 0 Dispense Cootaimnallt FIM(s) and Chain (sl 0 ispossar CosuniSensor(s}, Model: I)iqussset ID - Volvo (sj D-Vatva(s) 00' speuserContainmentSensor(s). Model: ty Dispenser Cknminment Heat (s) and Chain (s). a- har Valve (s} ID. 0 Dbpenser Cantairunopt FhAat (a) sad Cham (s} D r Conulmaent Sensor {s) Mode► Dispenser ID• l i Oar Valve (a) 17 -4bPf er Containment Sensor (s). Model: Q Dispenser containment Flea (a) and Chain (s) Shear Varve (s). Q Dispaoser Containment Moat (a) and Chain (s), •tf the faculty cattails shoe tanks or d-PetaYems, opy this farm. include inf lanstion fa every tank and disismer at the facility C. Cettifiead6o I..". that the e4ulpaseo9i4cadfied in this doeosnentesa lmspa&dhvvlced In ueordaiice with tee maoafactareek guidetlues. ,Utaehad to this CercWcatlea la taturmattem ('e. manofaetara' ehicWiats) accessary i verily that tete reports, I hs li correct and a Plot y an art howfag the tiyout of moaltorlag equlpmeat. For any equipment capable otgenerattng Saab rcporq,Ihavralaoattaehedaeopyafthet . (ekeejaUthmtgpy(p)r tHWitemset-ap 1T—AAiarmhistory report T ecbnician Name (print)- a,a I _ , „ Signature Mfg CartlY,: t,,c 1v` 'C""''CC# 50AAL01 +{ U i License.5184 CompanyNamo: Ser. Sta. Sys. Addles R ---�= No.: 408)971 2446 �fl? 0'. Ale. . �x Irt ^ r r 571 J Date of TeftlServcirl • ig- Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759