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MON RING SYSTEM CERTI ATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control 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 RAMOS OIL (FRENCH CAMP) Facility Name: 10842 S. HARLAN RD. Bldg. No.: Site Address: FRENCH CAMP, CA 95231 Zip: Facility Contact Person: ,, Contact Phone No.: ( ) Make/Model of Monitoring System: 7;Le_--o U 7�1('C' Date of Testing/Servicing: I D /1-7 /5 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: T nk ID: �,�i e_ -;4-... r Tank ID: In -Tank Gauging Probe. Model: �°.k ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. „ " Model: r ❑Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model:��';� ❑ Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: •'Mechanical Line Leak Detector. Model: i ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: _ ❑ Electronic Line Leak Detector. Model: Dank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (MecifX a ui ment a and model in Section E on Pa e2). ❑ Other (MecifZ Egpjnent a and model in Section E on Pa e 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s2eciEy a ui ment a and model in Section E on Eale 22. ❑ Other ec' a ui ment type and model in Section E on Pae 2 . Dispenser ID: I _ Dispenser ID: Z_/ --L Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Floa s and Chains). ❑ Dispenser Containment Floats and Chains . Dispenser ID: ispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model-�- y Shear Valve(s). Shear Valve(s). ❑ DiTenser Containment F12a s and Chains . ❑ Dispenser Containment FloLt s2 and Chain, s . Dispenser ID: 3 — - -Dispenser Dispenser Containment Sensor(s). Model: c -� ID: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment FI2Lt s2 and Chains . ❑ Dispenser Containment Floats and Chain(s). *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For - nequi ment capable of generating such reports, I have also att dyed a copy of the report; (check all that apply): ys yup larm history report ob Technician Name (print): Nei rY1�VCF Signature: ,x Q9AW9409a N0. LiGense� N0. Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Site Address: _10642 j- do-dan -Rd , Freoc� A►'=� Phone No.: (707) 446-6151 Date of Testing/Servicing: J_Q/ (1 405 Page 1 of 3 03/01 Monitoring System Certification