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ail"2/1995 03:27 2097546722 CALAVERAS ENV i At 01 PAGE H1 MONITORING SYS'T'EM CERTIFICATION Fc.,Ca.r r'. .:..leu.:.catiarts t{is ' suthoriry Cited: Chapter 6.7.Ifea/rh and Salery Code:Chaprer/6.Division 3. Title 23.Calrfaritaa Code nr'Regu/aero»s This form must be used to document testing and servicing of monitoring equipmenrt mu t more than one e monitoring system control patlel is installed at the facility,a to ce�rti'iicatio each monitoriniz system SgUMQ.-pancl by the technician who performs thL;work. A copy of this forret must be provided to the tank system owncT/°peAator. The ownerlopemtot must submit a copy of this form to the local agency regulatiOg UST systems within 30 days of test date. Instructions arc printed on the back of this page. A. General Information 8 3 Bldg.No.: Facility Name: r Cite Address:_ L 9® !A/ If V"/!r/t^ / fi A _ _ circ. t-Ji• zip. facility Contact Person: contact Phonc No..-( ZOO ) y7`e4/2 S Make./Model of Monitoring System: �� f 7LJr.3SO nate of TcsuaB/Serviciag: B. inventory of Equipment Tested/Certilkd Cheek the appropriate hoses to tudteste$ fie ai trent ins serviced: Tatak ID: Tank fD! -- ,�A•i �—�— -Tauk Gwging Probe. Modt:l: ` (!In_ Gauging Probe. Madel y� utx Space of Vault Sensor. Model d w 1B Annular Space or Vault Sensor- Model: t t Model: $UMPTrench Scn:or(s). Model_ IS Piping SompTrench Sensor(s). t s Ft Sensor(s). Model: 0 Fill Sump Sensor(s)- Model - Fill Lime teak Detector. Model: to Q Mechanical Line teak Detector. Model: Q Electronic Line teak Detector. Model• /1 0 Electronic Line teak Detector. Model: 8-Tank Overfill I High-Lcvd Sensor: Modcl: Y'! e® IS® Overfill ver lll I grog nt Sel Sem)r vlodel: �« �heu Valve(s)_ G"I ba"co Model: Va1ve(c}. Gs/ba rGp eDispaaa Canudruncot Flow(s)and Chain(s). a Dispenser Containment noat(s)and Chatn(s). a Other(s ci pment acid model in-section E on PaKc:. 0 Other(sBEcify a ui t type and model in Scetion E on Pate 2). Tank ID: Thak ID, ® in-Tank Gauging Probe. Model: d_/®r e.s Roc►t- 0 to-Tank Gauging Probe Model: Al Armular Space of Vault Sensor. Model: a` Q Annular Space or Vault Sensor. Model: 0 Piping Sumprrrench Sertaor(s). model: 0 Piping Surnprrreoch Scasor(s). model 0 Fill Sump Ssnsar(s). Model: Q Fitt Sump Sensor(s). Modet: it Mecbanxzi Line Leak Detector. Model: r Q Mechanical Line Lcak Detector. Model: Q Electronic Litz tonic Detector. Model:�ttC Q Electronic tine Liak Detector. Model. to Tani;Overfill I High-Levet Sensor. Model: T Q Tank Overfill I High-level Sensor_ Model: Q ispertser Contaitunmr Sertaot(S). Model r Q pispe"a Containment Sensogs). Model: mss-Valve(s). 4y"/kla/e a► O Shear Valve(s). G"Dignmer Canrainmeat Flost(s)and Chain(s). Q Dispense Contairunent Float(s)and Chain(s). 0 Other(s ut and model in Section E on PaSe 2). D Others i ui rnent and tnt>dei in Section E on P e 2. C. Certification - I certify t6st the equipment identified to this document was inspected/serviced in accordance with the msau[seturers' guidelines. Attached to this Certification is information (e.g. ttuaafscturcrs, checklists) necessary to verify that this information is correct and a Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the(checks all[hat apply): ®System set-up rgwrr -��_f yQ r Q Alarm hbtw v report- ,.-� e+" Technician N==(print): /J?'r de t g I'X __ CcnJLic.No.:_05&_7_3__S�twe- Testing Company Name: -��',f `� Phone No.:t ) PsZt 1 _V� osnarss Cigt.114-01 -- post-ir Fax Not,* 7671 DO. ro a To - wan t?it Q r_ F co.�. e0. 75 T 'd Zir89-19f' [60Z] umoig a t.t.ae0 eat, :80 ir0 22 �aQ