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05/19/2008 16:19 20936516 TANKNOLOGY PAGE 02 MONI OItIN s SYSTEM CERTI'ICAAN F'ot' Use Py All htrisdictions Within the S(rtte of California llrtlrnr'ift' Citt'rl: <'hcrpte'r b.7, Wealth errs([ Safett� CeVIV,' Ghcrj>tc+r' lE, lilt+tsigtr i, iitPG+'j. Cull'{oi7rirt Crjdc ul R«'+rlertiuyrs his litrnt rzlust iat ttsl:d to document testing and servicing of monitoring equiprnent. A se at -ate certification or re ort must b re ared s st�rrl controk Anel b ds6 technician who performs the work, A copy of this corm must be provided t tits rink )r each 1�10nitoritlt v � of this fonn to the local agency rcgulatitlg US'T systems ""thin 30 ystct l owucr/operator, 'Tile t)wricrlo,erator must submit a COPY nysol'lest date. k. General information ,acility Name' �t�s iitc Address:v_3..._G 'acility Contact Person:_-� LCiry 13ldst. No.: Contact Phone No.: g Y .�.�. Date of Testing/St:n*icing,: Q vlakcJvladclOrMonitorin S stc � � B. inventory o!' Equipment Tested/Certified Check ro 1'taLe Ifoxes EU indicate SP CCMc equip intnt ins 1,5 ❑ In -Tank Gauging Pro1x:, O Annular Spacc or vlujit Scnsor. * Pipinu 5utiip / Trench ScnsOr(s), E) F III Sunip Scnsor(s). i`icchanical Linc Leak Detector. F.locironic Linc Lcak Detector. Q '1"ank O\,cr(i11 / 1-1igh•LVOI Sensor, Q Othcr (s ccif c ui �mcni tv ee nd I Tank )U:_"�- 0 In -Tank Gttuging Frobc. ❑ Annular Spacc or Vault Scnsor, ❑ Piping Sump /'rrcnch Scnsor(s). Fill SUMP Scrosogs). mcchanical Linc Look i)ctcctor, Electronic Linc Leak Detector. 0 "rank Ovcrfill / l-lig:h•L.c%jcl Scnsor, model - Model: Model: Model:.— Model: — Model: Model: „ndei in Section E on Pa gcb 2). model, Model: Model: Model; Model:�.— Modcl: Model: model in Scctionis oro Pae 2). Dispenser ID: __, p Dispcnscr Containment Sensor(s). Model: C� Shcar Valvas). L7 Dis cnser ContRinmcnt Flouts) Lind Chain (5 . 1] irenser ID: ❑Dispcnscr Containment 9cnsor(s), Model: 0 Shcar vahle(s). © Disucnser Containment Float(s) and Chains . Dispenser' ID: ..� .._._..:_ — Q I�ispertjer Containmem Scnsor(s), Model. Tank ID: -I I__—.—._._�...... M In -Tank Gauging Protre. Model;— Modei: Q Annular Spacc or vault Sensor. ❑ Piping Sump/ TrenchScnsor(s). Modcl: _ _..—•__ _-. Fill Sump Sump Scnsor(s). Madel: _— _ —.... •-- Mechanical Line LCak [)elector. Model; FFFttt�� Electronic Linc Leak Detector. Model: _ �, •_ — �j Tank Ovcrfilt 11-1igb.Lcvcl Sensor, Model: _ _... modcl in Scction C on )ac;c' )• CI Other (specify ui ment t and Tank ID: C) In -Tank Gauging Probe. Model: _ __• -- Q Annular Space or Vault Sensor' Model:----,, -_ -- ❑ Piping Sump /french Scnsor(s). Modcl: ® Fill Sump Sensor(s). Model: ❑ Mechanical Linc Lcai<Detector. Model: ❑ Electronic Linc Leak Detector, Model: ® Tank Overfill / High -Level Sensor. and Model: model in Section E on C,1 Other (s CCif ui mcnt t Dispenser ID: a Dispenser Containment Sensor(s). ^� Model:.,.•-„•_._�„�_...�. --•- ® Shear Valvc(s). ® Dis cnscrContainmentf•loat(s)andChain(s). Dispenser ID: —�--- '' ❑ Dispenser Contaimncnt Scnsor{s). * Shear Valvc(s)• p Dis cnser ContainrAent Float(s) and Cltain(s). Dispenser ID: Q Dispenser Containment Sensor(s). Modal: __-•a,r_ �_ .__.._._T_—..�.,. ❑ Shear Vaivc(s). Q Shear Vah•c(s). • ❑ Dis cnser Containment Float(s) and Chain(s). ❑Dis enscr Containment F1ont(s) and Chains . if the 1'acilirj, contains more tanks or dispensers, copy this fOrm, include i»formation for every tan and dispenser at the facility. C. Certification - 1 Certify that the equipTnent i(jentified in this document was inspectc&servieed in accordance with the aria tufacturrrs' };ultictitSCS- Attnclied to this Certiiicntion is information (e.g. manufacturers' checklists) necessary to verify that this w ormation is correct and a Piot' Plan clawing the layout of monitoring equipment. For any equipme [Cada ole oreport eerting such reports, t have niso attached a cop)' of tine r p rrt; (check 0 thht apply): � system set-up ®,A� y signature;�M _ .....� Technician Namc Orin,,, __ r _ 1_3 Ccl-tilication Nq.; Phone resting Company Name: Date of Tcsting/Servicing; Site A<)ds'css: Nage t of U3A) I Nionitorirn, $�'stctil (`crtincatitrn