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03703/2011 11:23 5596881467 FRANZEN HILL PAGE 02 Appendix V1 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htt:llwww.wate[b_oards.ca. ov.} MONITORING SYSTEM CERTIFICATION For use By All Jtllf dkd0n3 WPthilt the Stats of C86forrtla Authority Cited. Chapter 6.7, Health and Safety Code, Chapter 46, Division 3, Tide 23, Calfffiornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared far A copy of thle form must be provided to the tank system each monitoring system control panel by the technician who performs the work, UST systems within 30 days of teat date. ownerloperator. The ownerloperator must submit a copy of this form to the local agency regulating A. General information Bldg No,' Facility Name: , LaNtrop�b.911 Sitio Address: 1�Q S Harte» City J athroc Zip: - Facility Contact person: Nick -Cordact Phone No.: (2A—) 4 58 MakelModel of Monitoring System: TLS " aQ _-- Date of Tedingiservicing: 02LQ71201 - _— B. Inventory of Equlpment Teste4lCertifled CheCRADURRE91KIdetxs - e s i t serviced- Tank ID: 0 • �Re9i�ar _ F In -Tank Gauging probe. Model: Na Tank 10-83 - �it)fe1 E ire -Tank Gauging Probe. Model: 14g E Annular Space or Vault Sensor. Madel: E Annular Space or Vault Sensor. Model: E Piping Sump i Trench Sansor(s). Model: ULS E Piping Sump I Tranch Sensor(s)- Model: 209 Model: E Fill Sump Sansor(s). Model: 2d8 E Fill Sump Sensor(s). E Mechahical Line Leak Detector. Modal: VMI E Mechanical Line Leak Detector, Model: Petro F. Electronic Line Leak Detector. Modal 8 Electronic Line Leak Detector. Model: i3 Tank Overfill I High -Level Sensor. Model; F Tank Overfill 1 Hlgh-Level Sensor. Model: ,flap E Other (specify equipment typo and model in Section E on Page 2). E Other (specify equipment type and model in Section E on Page 2). Tank ID: #2— 91 Premium E In -Tank Gauging Probe. Model: 109 __ Tank ID: - is In -Tank Gauging Probe. Model! E Annular Space or Vault Sensor. Model: _40_ __ E Annular Spate or Vault Sensor. Modal: - R Piping Sump I Trench Sensor(s), Model: E Piping Sump I Trench Sensor(s). Model: 208 Model: E Fill Sump Sensor(s), Model: E Fill Sump Sensor(s), T Mechanical Lina Leak Detector. Model. VMI___- _ E Machanicat Line Leak Detector. Model., — Model: E Electronic line Leak Detector. Model: E Electronic Line Leak Detector. E Tank Overfill I High -t oval Sensor. Model: F Tank Overfill 1 Higte-Level Sensor. Modet: flab E Other (specify equipment type and model in Section E on Page 2). B Other (specify equipment type and model in Section E on Page 2). Dispenser 10, 1 Dispenser Containment Sensor(s), Model: Dispenser IM. 7 • B _ Dispenser Containment Sensor(s). Model: Shear Vstve(s). X Dispenser Containment Float(s) and Chain(s). Shear Valva(s), X Dispenser Containment Floats) and Chale(s). Dispenser ID: 3 - 4 Dispenser Containment Sensor(s)_ Model: Dispenser 1D: -. F. Dispenser Containment Sensoria). Modal Shear Valve(s), E Shur Valve(s). F,. Dispenser Containment Flo s and Chain(s). X Dispenser Containment Float(s) and Chains . Dispense r la S - 6 Dispenser Containment Sensor(s). Model: Disperser ID E Dispenser Corrtairunent Sensor(s). Modal; Shear Valve($). E Shear Valve(S). E Disporw.cr Containment Flost(s) and Chaln(s), X Dispenser Containment Floats) and Chains *If the facility contains more tanks or dispernsen- copy tltts form. Include information for every tank and dispenser at the fecttity. .....r., .rte C. CertFBaaitlon - I certify that the equipment ktetdified in this document was inspemeouserwaeo rn 4&&4 moo- manudactarem' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verily that this Information is carred and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, l have also attached a copy of the report; (check all that aipolyp E SystgsLlsett-1u E Al nn history report Techniclan Name (print): Sfthert & ahlgn Signature: )`✓" Certification No-: 4341047029_ License, No.: o — Testing Company Neme: H' I phone No.:( Testing Company Address: 1110Q N J St[ee?`T" r"�^ CA 93274 __ — Data of TestingiSetvieing ,T.( LZQII— Monitoring System Certification Page 1 of d 92M7