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r i •i oitori stem EquipmentArtification For Use&.411.1urisdictitms within TheState uJ C'ati/ihr nkr F .4whoriw Cited•Chapter h.7, Health and Saki,Code: Chapter /h. Division 3• Title 2.3. C'alilor-nia Code n!1 egulatiun.s This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must he prepared for each monitoring system control panel by the technician who performs the work. A copy of this forst most be provided to the tank system owner/operator. The owner,'operator must submit a coPy of this form to the local agencq regulatine UST system within 30 days of test date. A. General Information Facifiry Name: Chev 99840 Bldg.No.: Site Address: 4344 Waterloo Rd City: Stockton, CA lip: 95215-2306 Facility Contact Person: Contact Phone No.: (209)931-2186 Matte/Model of Monitoring System: 11 VL "I L--S S� Date ofTestingServicin S ') 13. inventory of Equipment Tested/Certified (heck lite appropriate bodes to indicate specific equipment inspected/serviced: Tank ID Tank IU ❑ In-Tank G;tagins Probe. Model: ❑ in- ilutk(iauging Probe. \indcC nnular Space or Vault Sensor. Model: �► ❑ Annular Space or Vault Sensor. Modell cWfipins Sump.'IYench Sensor ts). Model: ❑ Piping Sump,'Nesse Sensor(sl. Model: ❑ Dill Sump Sensor(s). Model: ❑ Pill lump Sensor is). Mudcl. ❑ yKchanical I.me Leak Detector. Mode: _ ❑ Mechanical Line Leak Iktector Model dl,leeuonrc Line I.cak Detector. Mcxlel: _ ❑ Electronic Linc I cak Iktector. M•xfcl lank(?scroll Ili=h L eve)Sensor. "Wel: [3 lank Ucerf ll I liall-Level Sensor. Model: ❑ , ? oilier(s city c ui mcnt I%Pc mil model in Section I on I a_tc 2). ❑ otiwr i specifixquipment type and model in Section I:on I a-e_). ❑ Pc' q P P' Tank I ��.11`` Tank iD ❑ In Dank Gauging Prc,be. Model: ❑ In- I ank Gau,m:;Probe. Mcxiel Do,�'Utnular Space or Vault Sensor. \lcxlcl: O Annular Space or Vault Settlor. Model: gj/(ipme,Sump'a rentdt Sensor(s). Mcxlel: ❑ Piping Sump\Trench Sensor(s). Model: ❑ hill Sump Sensor( ). "'lodel: ❑ Dill Sump Sensor isi. ModcL ❑ >techameai I ine I cal,Iktector. Model: r ___ ❑ Mechanical I ins I cal,Detector. \Dods) el lectromc line I cak Detector, Motel: ❑ Electronic Lind I eak Iktector Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ 'i ank Overfill I h<,h-1-ocl Sensor. M'.&: ❑ ()dter t specie}'equipment type and model in Section Con Page 2). it ❑ Other I spceily equipment type and model in Section 1 on Page:-'). Dis eraser IU• 1 2- Dis ser ID ? Doottspenscr L ontainhient Sensor(s). Model: O Dispenser Containment Sensof is I. \L,del: ❑ Shear Valve(s). ❑ Shear Value ts). ❑ Dispenser Containment Float is)and Chain(s). ❑ Dispenser C(intaimncnt Float ts)and Chitin ist. fa I)Apenser tU 3 UiIn �tpenser IU• Dispenser Containme Sensor(sl. \14,00: Ey Dispenser Containment Senso ills \Dude) ❑ Shear Valve is). ❑ Shear Valve is), ❑ Dispenser Containment Float tsi and Chain(s). ❑ Dispenser Containment Float(s)and Chain W. Dispenser IU t)i nser Ii) 11 t)isprnser Containment.ensor(s). Model: `� Dispenser Containment Senso ts). Model: e7^� ❑ Shear Valve(s). ❑ Shear Valve is). ❑ Dispellser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float ts)and Chain+st. "If the facility contains more tanks or dispensers.copy this form, Include information for every tank and dispenser at the Lacibly C.Ce'rtillCation I certify that the equipment identified in this document was i1espectCd1seniced in accordance With lite ma m.faelorer's guidelines. Attached to this Certirtc•alion is information(e.g.manufactures'checklists)necessary to verif.s that this information is correct and a Plot Plan showing the layout of maniloring equipment. For any equipment capaMe of generating such repbrts.I have liko attached it cope of the: (check all that uppity): ❑ S%stem set-up ❑ Alarm histore rt r I echnician Name(print): Tou Lee Signature: _ �1t�.C;ett: .: 137SaTi1� ICC# rsylo- SA- 10 IL License. N 4 18 festin Company Name' Serv.Sta. Sys _ 1 e 8 .91. 2445 'testing Company Address: 680 Quinn Ave.,San Jose CA 95112 c • c,st , So•yicini NOV 0 4 200 SAN JDAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT