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MONARING SYSTEM CERTIFOATION For Use By All Jurisdictions Within the State of Ckllj�*-gjtim, Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 2FrC;1 Cdi404tulations ?V,cr_ This form must be used to document testing and servicing of monitoring equipment. A semata rertification or re ort must be prepared for each monitoring system control panel by the technician who performs the work. A coy ovided 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 InfQrmation Facility Name: Q„� &4-6Q nn --'' Bldg. No.: Site Address: E a �'{� $ , i�(titr�(r rt t�Gt , City: Pre et, Co—t.0 Zip 'T.Si3t Facility Contact Person: o�g ,t,,,- Contact Phone No.: Uog q 4 5 3l)__ Make/Model,of Monitoring System: Xm aw IS 100 U d RE Date of Testing/Servicing: j, -;L1- 03 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment insnertefikervire : Tank ID: j Cib-y( Tank ID: In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: 'Annular Space or Vault Sensor. Model: Ja/y S ❑Annular Space or Vault Sensor. Model: (,jPiping Sump / Trench Sensor(s). Model: U LS ❑ Piping Sump / Trench Sensor(s). Model - 6d 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 (specify equipment type and model in Section E on Page 2). ❑ Other (speciLy equipment t e and model in Section E on Page 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 (specify equipment ty e and model in Section E on Pae 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: % ..�_ Dispenser ID: 3�y (�-jDispenser Containment Sensor(s). Model: U LS 12 -Dispenser Containment'Sensor(s). Model: Ja'Shear Valve(s). Ui Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: -Er Dispenser Containment Sensor(s). Model: V ❑ Dispenser Containment Sensor(s). Model: &'Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensur(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). _ ❑Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chains . 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/se.rviced 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 any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): system set-up Alarm history report Technician Name (print): LEE A. WILLIAMS Signature: Certification No.: `-77/-0a 0 4If License. No.: 03160 Testing Company Name: Stockton Service Station Equipment Co. Inc. Phone No.:(209)464-8333 Site Address: Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification