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MONITORING SYSTEM CERTIFICATION <br /> For Use by All J0fisdictions within the State o fc­afil,�,rni,? <br /> Authcrity Cited-Chapter 6.7, Health and Safety Code. Chaipter 16 o'! 'Ve C-i to; ;l ��, <br /> This form must be used to document testing and servicing of rnonito_ri�q, equspoik,ol. /I separate c,,(,1rI1ftCdV cry rvp <br /> "I . - - - , - Ltin <br /> tr <br /> must a Bared for each monftodna system con#W a/Zq/by the techn icia,n '.Melo'.Meloer <br /> oforms e 4`, copy of t t'i� fof m-;_#eALp p__ <br /> must be provided to the tank system owner/operator. The uwnerlopeiat�oi n-,u_il .3 t.r',3 forf; �to the lc_;cal <br /> agency regulating UST systems within 30 days of test date. <br /> General Information <br /> FA hiy Name Wilson 2iiEciievwrr�- <br /> Site Address. 437 N. Wilson SJcKtoo <br /> MGR I Owner <br /> Facilrny contact Person. <br /> sysiem Veeder Root TLS 350 <br /> B. Inventory of Equipment Tested/Certified <br /> CIAW,k f/War ropraetebaKes to_ii,idicafq:d-EEgLeLa iners f"1!11 <br /> Tank ID:Unleaded '_,nk;D <br /> In-Tank Gauging Probe. Model:Magnostrictive ED it--a­ <br /> Annular Space or Vault Sensor. Model:794320-407 Q Anni <br /> Piping Sump I Trench Sensor(s), Model:794320-208 <br /> Fill Sump Sensor(s). Model:794320-208 Q Fill '94320-208 <br /> Mechanical Line Leak Detector. Model:FE Piero MW Q Mec i jacks' X l'i <br /> Electronic Line Leak Detector, Model: <br /> Tank Overfill!High-Level Sensor Model: lar* J; 1, <br /> Other tspeci equr men ,y and model in lectionan Pa <br /> Tank ID: Tank 1D: <br /> 0 In-Tank ank Gauging Probe. Model: <br /> Annular Space or Vault Sensor. Model: El Annuiai �iit Modi <br /> Piping Sump I Trench Sensor(s), Model: Q pipov! <br /> E] Fill Sump Sensor(s)- Model: Fl <br /> Mechanical Line Leak Doimtor, Model: <br /> Electronic Line Leak Detector. Model: :7 Flec*i,.- 'M'r,d e <br /> Tank Overfill!High-Level Sensor Model: Wdk�= <br /> ether ecffequipment type and model in Section E o�Page 2,1, <br /> _ del frj�� <br /> Dispenser ID: 112 Dispenspi ID 3j4 <br /> Z Dispenser Containment Sensor(s). Model:Veeder R 12-0011 ,i <br /> got 320 Dispe,��el Model: 7"co3 001 <br /> Shear Velvets) Shear <br /> Dis user Containment Floats)and Chain Ll Dispefist­ oi oi t 1tt <br /> I Dispenser ID:5/6 Dwensor <br /> EDispenser ContainrizeritSeitsor(s). Model:Veederftot32012-0011 <br /> Z Shear Valve(s). Shear <br /> Dispenser Containment Floats and Chain s). Q Dlspens )Jf w:or; i foa!"'I a <br /> Dispenser ID: Dispenser iD <br /> Dispenser containment Sensor(s). Model: <br /> Shear Valve(s). Shes, al--, . <br /> Dispenser Containment Floats)and Chain(s), <br /> —If Itieh9cility contains more tanks or dispensers.copy this fol-In, <br /> C_Certiftailion-1 certify that the equipment identified in this document was inspectediserviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is the information(e.g.manufacturers'checklists"necessary to verity that this inf()rrnati4-.)n is <br /> correct and a Plan showing the layout of monitoring equipment- For any equipment capable of generating such reports, I have also <br /> att;ach�ed a_copy of the report; (chec*all that apply�Q System set- Alarm hisTori report <br /> Technician Name(print): Kevin R. Matlock <br /> ICC Certification No: 5069874-UT u SWRCD 02-1633 <br /> T esling Company Name: Cie is Solutions, Inc. 769-,' <br /> 52 15 <br /> Addresses� P.O.Box 3917, Merced CA 95344 03/03/2008 <br /> Page 1 of 3 <br /> 031011 <br /> Monitoring System Certification <br />