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MAR -31-2008 12:18 Service Station Systems 408 938 8888 P.02 • MP ti mon, g System' ment Cer' ficatio In 7i$xafOHwnAe&a1eqf California Authority aced: Chapter 67, ReafthandSafi.?O, Code; Chapter 16, Division 3, 21irle 23, California Code of This Eosin must be'w9d to dowment testing and AML 9 so vicing.ofmohitoz* equipment Aseparate certification ors port must be preo&ed -for eaAinqnagjWg ;yon qo tr6 mnal 'by the tedlARICIM Who PttfOrms the work. A copy of this form must be provided to the system owner/operator. The owner/OpOrator must submit a copy of this form to the local Agency regulating UST system tank within JO days of test date, A.'GelkerW hii fanution P Faegity N&M. Bldg. No.:i. Site Ad&ess:.3321_)� Ci zip. 9f ? (0 ty. Law Facility contact Contact f Phone No,: 3S'_ 7 (Pb- Mak.U.61 of Mo.1t9ft sygtew - ----- Date of Testinoervicing.-I.: B. lnventoryvf Equipiaent TestedtCerd&4 Chea the approprlite bold ftl4diote Speeffic gqj4plentluntekedlaerviud! T r a W1 17 13 In - Tank GaVas Probe, Model, 13 Annular Space ar Vault sonans, Modal: 041Pi1k9 SUMP N Trcitch SOM(s), MOM: a FBI SUMP Series (a), Ma". 13 Machnical Line Leak DckcW. Modal: 13 SlccftfiicLine UakDa=tor. Model: 13 Tank 0verWXMXb-1&vcdsww_ mod,4- 13 Other ( specify sqifpmant type and model in Section E,on Page Tartu In, 13 J2-TAuX.U&*ngInaba, Model: 13Space or Vault Sensor, Model: =8 sump X Truth Sensor Model: [3 Fill Sump 5ensor#).. .. Model: 13 Uschanical Lhw LeakDetw . tor, Model; ------- 13 Electronic Line Leak Detector, Model; 0 Tank Ovalft \ MA -Level Sensor. modd 13 Otb or (spac* dquipmew " and model in Section E on Page 2 0 Dist Contaimnent Model; 6-617voajvv(s} - . (] Dispersert Float (s) d Chain (s). DM=cr 13 f1 ConWamentSonsorft mud�j: Vulva (S(S),=.. 13 Dispenser Containment Float (a) and Chain (a), i W-5-11MM 13 In - Tank Owgiag Probe, - - Model, E3 Annular Space or Vault Sensor, model, 5'4i49 Sump k Trench Sensor (s). Modal - 13 FBI Sump Scoot (s). Ma". E3 Mechanical Lim Leak Detector, Model: 13 Electronic Line Lq* Detector, Model. 0 Tank Overs k MO-Ldve.1 Seasor. model: 0 Other ( specify quiPMORt" and modal! inSoction Eon Page 2), Tank I a In -Tank Gauging proh,% Modal: 0 Amular Space orVault sftwr, Model: O'liping Sump 1 Trench Sensor (s), model: e-c)x 0 Fill Sump Scoot (s}. * Model: 0 Mechanical Lim Leak Detcator. Model: 0 Electronic Liu Leak Detector. Model, 13 Tank Overfill 1 High-Uvel Sensor. Modal' 13 Other (specify equipment "and model in Section E ouNgc 2), Dl%unr ]D.-, 13 V . Wser C6Dt3inMcQtSeer (9). Model: D4hw Valve (s} 0 Dispenser Cdntxjnmut Float (g) and Chain (S), D40wer ID; 103 nhwam Containment Sensor (s). Mcdcl: j4hear Valve 0). 13 Dilpauscr Containment Float (s) and. Chain % oc=rts). 9 ro ontainment Sensor (G). Model: hear Valve (s),13 Dispeaw ContainmentbFloat (s) and cajn (s) 11 DiWnsar Containment Flog (a) and Chain (4 W U facility contains iuorc tanks of dispensers, copy this form, Include information for every tank and dispmw at the facility C. Certfflcafloff® 1 'art'fy that the 644mcftt *Qificd is this d0clU0989 Was inspocteNseftleed to accordaiice with Me Attacked to this Cartificadou Is Information (c,& necessary to verify that this informatiai is correct sad a Plot Plan shovd4g the layout of monitorlsig apipment, .For ally equ4x=t espabic atZeneratiog sack reports, I hivw also attachad a copy of thy (checi.&Hhaigply). to ,set-up Vlarm history report Tediniamn Nam .(priut)., Signature: W& C ft to.: - WO q-(Pf -07 License. N4--399184 0 C6mpuy Nw= Ser. 51119 Phone No.: 4001 1-2445 ON 9971> Date of Testing/Servjcjn&:3,-,>j--Oj