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M MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chaplet -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 monitorine 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 Information Facility Name: STOCKTo0 NASA Bldg. No.: Site Address: 2-0 )Q STI -4 S 0 t�,j Wo City: STOC V7DN� Zip: Qt 5-2-O (A Facility Contact Person: SFC- ? I CA _ Contact Phone No.:( _ZL—F _)_ at 83 - S3�' Make/Model of Monitoring System: t _Q W Ad _S %I 1C , R Date of Testi /Servici 0 B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to Indteate snecnne en„nn.n t °... ..-w.--_..__- Tank ID: -r v A, 1 15 K Model: �t- &P -`tom_ 0( In -Tank Gauging Probe. Model: TSP - t t.,Z, Annular Space or Vault Sensor. Model: T 54 - ut.5 Piping Sump / Trench Sensor(s). Model: TSI'- vLY Cl Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Othereci ui ment and model in Section E on Pa 2). Tank ID: Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: O Tank Overfill / High -Level Sensor. Model: 13Others i i melt and model in Section E o P 2 Tank ID: -rQK 2 ZoK fiir In -Tank Gauging Probe. Model: �t- &P -`tom_ ,B( Annular Space or Vault Sensor. Model: T S 11— UQ% ❑ Piping Sump / Trench Sensor(s). _ Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other eci ui mett type and model in Section E on Pae 2). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detecior. Model: ❑ Electronic Line Leak Detector. Model: O Tank Overfill/ High -Levet Sensor. Model: n a14 Other meat a and model in Section E on Pae 2). Dispenser ID: TRA AS , Su n^� DispenserContammentSensoc(s). Model: Dispenser ID: i2 f.£L VC_ rS P- OLS ❑ Shear Valve(s). Dispenser Containment Sensor(s). Model:t" s P- O1 $ ❑ Dispenser Containment Floats and Chain(s). ❑ Shear Valve(s). Dispenser ID: ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Sensor(s). Model: Dispenser ID: ❑ Shear Valve(s). ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Floats and Chain(s). ❑ Shear Valve(s). O Di user Containment Float s Dispenser ID: Dispenser ID: and Chains . ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). 11 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Floats and Chain(s). ❑ Shear Valve(s). •If t ❑ Di enser Containment Ft s and Chain(s). the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C- CertiflCati0n - 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° c cklists) necessary to verify that this Information Is correct and a Plot Plait showing the layout of monitoring equipment. For any equ ;Vtblegenerating such reports, I have aflso attached a copy of the report; (check aU eha[ apply): Q System set-up Q� re rt Technician Name (print): U__C Tt� (Z AL4 1 Po �iS`. Signature:l Certification No.: License. No.: Testing Company Name: _ Phone No.:( gO ) (s52- 006 _ Site Address: a 14Y SN ERtxjit.� Ay . %L_ \(gN TQ RA 930®3 Date of Testing/Servicing: 12 / a /