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MONITORING SYSTEM CERTIFICATION For Use Authority Cited- Chapter 6.7, Neal h and Salfety Code; Chapteffisdictions rr 16,the Division Tilffornia tle 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must I ., Cor each monitoring system control reDared 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 FacilityName: S T0CKTo0 & ASF Bldg. No.: Site Address: 2oOf) TIu6150t� RD City: �TOC1�Tat�► Zip: 1 5-2-C)(,,— Facility Contact Person: SFC tm} i AtJ t!� 1 C(, _ Contact Phone No.: ( 2Q5 _) of 83 - 5 Z� Make/Model of Monitoring System: t._&k3 A�`LDate of Testi/ � [O S ` t K Ji? ng/Servicing: l /0 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to lndlrm, .n m Tank ID: TvjY, 1 IS IC (51' In -Tank Gauging Probe. Annular Space or Vault Sensor. Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (specify eouiatnont type and r Tank ID: ❑ In -Tank Gauging Probe, O Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sonsor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. Cl Tank Overfill / High -Level Sensor. ❑ 0�(sp x niprne nt type and n Dispenser ID: MRAh15 �tJev� Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats) and Dispenser-- I --D:- ❑ Dispenser ContainmentSensor(s). ❑ Shear Valve(s). Cl Dispenser Containment Floats) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). *If the facility contains more to ks Model: Tank ID: 'TQK 2 Model: Model: i'S i LL fiif In -Tank Gauging Probe.Model: i"5 -P Model: Model: Ts 7 L s J( Annular Space or Vault Sensor Model: __ t^c w lti,I _ Model: ❑ Piping Sump / Trench Sensogs). Model: Model: ❑ Fill Sump Sensor(s). Model: Model: ❑ Mechanical Line Leak Detector. Model: Model: ❑ Electronic Line Leak Detector. Model: iodel in Section E on Pago 2). ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other fsneciry t.-n..;n............._ .._j Model: Tank ID: CI In -Tank Gauging Probe. Model: Model: Model: ❑ Annular Space or Vault Sensor. Model: 11Piping Sump / Trench Sonsor(s). Model:Model: Model: 13 13Fill Sump Sensor(s). Model: Model:11Electronic Mechanical Line Leak Detector. Model: Model: Line Leak Detector. Model: ndol in Section E on Pae 2). ❑ Tank Overfill / High -Level Sensor. ❑ Other Model: ui mcnt c and model in Section E on Page 2). Divpenser ID: Model: 1`S 1p- tt j�DispenserContainment Sonsor(s). Model Chain(s). O Shear Valve(s). ❑ DisnenserContainn,e,nt ___._. Model: Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Ch! in(i Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain( n or dispensers, copy this form. Include information for everytank and dispenser at the facility. C. Certification Attached - I certify that the equipment identified to this document was Inspected/serviced in accordance with the manufacturers' guidelines. An Attached to this g t tWcatitvn Is Information (e.g. manufacturers' c ecklwsts n correct and a Piot Man showing the layout of monitoring equipmethat this Information Is nt For any eqn nt) b off generatinry to g such reports, i have also attached a copy of the report; (check all that apply): Cl System set-up ® st report Technician Name (print): JA_ C TM R 466 Po Signature: ' Certification No.. ) LA 11 5 ig S i t� License. No.: %-1'2 h. Testing Company Name:1AIJ K TE.q�Y, Phone No.d 80! ) (� S - ®O (,] Site Address: 2l�}$' S}1t:R 1 y,y� Ay t� �/EN� 9300-3 Date of Testing/Servicing° �/�/� •