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Y i 05/19/2008 16:19 2093651 TANKNOLOGY MONITORING SYSTEM CERTIFICATION For ust 93) All Jriris(Ifulans WWI the state (if California : hrthr,,rih Citerl: ("'l)(1pier f>, 7, Health Areca selfefy Cada; Chaps r 16. Division 3. Tirfe 23. Cer/ir�mirr C dc' u1 1_1 3 2008 ']]is liTYt13 rnkTst be cued to docunlcri( testing and servicing of tnoniloring equ.ipmea.t. A st a'ate cert! tcatton Or $!�w or each 111g,litoritt>~ _,y_tcnzcunErol palzet by the technician who performs the work. A copy of this form 1110St be proti ided i ystem 0\1,11er/operator. 'I'lie awner/operator must submit a copy of this tonxt t0 the local agency re ulatiTT LIST s}'stl n1s lays ol'test date, k. General ilnf aiion 'acuity Name!Le%Jp_ >ite Address: ;UCility C(Untacl Person: ,lake/Model of M01*0rirlg Systctn: B. Inventory of Equipment Tested/1Qertified •-,leek Ibe aciorooriate taxes to ihdicUc ypeClt3c eQuiti,ltent instwe hank ID: In=1'tmk G:tugin}; f'roUc. Model: nttular Spacc or Vault Scnsor, Model: ,[ _ Q piping Sump / Trench Sensor(s). Mode(: Q till Sump Sensorfsl• Model: C3 Mechanical 1,inc [.cul Detector. Model-___ lectronic I.,= Lcak ieteclor, Po-ankSensor. Model: Modci; Overfill / I litth-Lcvd _41S 0 other (s ecil'v c ui 5nlcnt t )e and model in SeetlionE on Pa yc 2 . Tank I i3: C. Certification - I certify that the equipment Identified in this document was inspected/serviced its accordwice with we may l3 In -Tank Gauging Probc. Modcl. _ _ -- Q Annular Space or Fault SL'nspr'. Model: ❑ Piping Sump / Trench 5ensor(s). Model:.— odel,C1 C2Fill Sump Scnsoq'i). Model: 0 Mcchunical Linc Leal; Detector. Model: a Electronic Line Lcak Detector, Modcl: * TWOsvrfifl / l•lii'114.cvet Scnsor_ Model: _. ❑ OtherLsp e{�f'Pc�iSa+ nt me c and nlodcl in Section E on Page 2}, City. _ Bldg. 1\10.:, - lila: ICES ttie usnk ithirt 3() Contact Phone Ne.: ( .).___..M__..._...._i...-._—._. Date of restinJServicing; Tank ID; _ - 0 1n -Tank Gauging Probe, C1 Annular Space or Vault Sensor. ❑ }piping Sump /Trench Scnsor(s), O Fill Sump Scnsor(s), ❑ Mechanical Linc Leak Detector. ❑ Electronic Linc [,cafe Detector. ❑ Tank. Overfill / High-Lovcl Sensor. 12 other (specify equipment typc and Model: (vlodcl: Model: Model — .. ivlodel;-- Modcl: lodcl in Section E on age'-),_ Tank ID; 0 In -Tank Gauging Frobc, Model; ❑ Annular Space or Vault Sensor. Model: Q piping Sump / Trench Sensor(s). Mode(: ❑ Fill Sump Sensor(s), Model: O Mechanical Linc Leak Dctcctot. Model: 13 17'lectronic Linc Lcak Detector, Model; © Tank Overfill / high-Levof Scnsor. Modc1: * Other (soccify equipment type and model in �mo2xcn 1f): iSpenser 1D: �.—.___..--... 1?ispeaser ❑ Dis cnscr Containment Sensor(s). wloc c : __...,...—..._.__..._,.,.._-- Q Dispcnscr Containment Sensor(s). Modcl: _ P C:3 Q Shcar Vatvc(s). Shear Valvc(5}, ❑ Dis enscr Cpntaint11cn) Roars) and Chain(s). Q Dis cnser Containment Floats) and Chain(s Dispenser 11.): ,- . Dispenser 1I): ❑ Dispenser' Containmcn( Scnsor(s). D15peITSl:r CantarnllTcrTt SCnScar'(s), ! : ,- * Shcar Vul%-c(s). Q Shear valvc(s). Ll Uis oresc�r Containment 1= 51 and C.htiin(s}, ©1]i5 nscr ContainmCtt .at(s) and Chain( -O.. _—. Dispenser ID, —r r— _� Dispenser lila ensor(s), Model; 7 Dispenser C' ainntent Scnsor(S). Model: Q Dispcn oniainmwl M Shcar V vc(s). EI 5 alvc(s). ODis enscr Containmcnt Float(s) and Chain(s). 0 Dis cnscr Containment Floats and Chain(s). '1 rthe fncilit), contains more woks or dispensers, copy this Form. Include informution for every tank and dispenser at the facility. C. Certification - I certify that the equipment Identified in this document was inspected/serviced its accordwice with we may utacturer-s' Ruidelines. Attached to this Certification Is information (c.g. manuf'acturer's' checklists) necessary to verify t11n1 this w rmation is ctarrect :a,it1 al Plnt Plata sboxving cite layout of trtopiiurittR equipment. Rm any equipment ca ncr h reports t have ,,f5n attatcfted a Copy of the re c t tH t arppl , • System set-up � armart Technician Name (i36111):Stgnaturt:. _ ___........_.............._.. C:crtircation No.: License. No.-----.. 'f csun�, Company Name: -- —hone /saw �.- Tessin */Servicin g 7 Site Adch•ess: _„ Date 0f b 1: i':tec 1 of 3 Monitoring S}'steni C'er-tificnilnn a1rb 1