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FEB..25.2003 1O:49AM SCOTT CO NO.615 P.37/4O t MON17ORING SYSTEM CECT CATION For Use By All.lurUdicrionx Within the State of CalrV'ornfa Aurharfry Cued: Chapier 6,7, Health and Safely Code; Chapter 16, .Division 3, ?"alto 23, California Code of Rtgulasfaps This form must-be used to docpment testing and servicing of monitoring equipment, A sepacM esrtifieago orreport muskhe ores nand for each monitoring sv tem control onnrl by the (cchnician who performs the work. A ropy of this form must be provided to the tsnk system owner/operator. The owner/aperatvr must submit a copy of osis form to the local agency renultatitsg VST systctrts within SQ days of test date. A. General Wgrmation „�. ' Facility Name: ti r Bldg. No.L— SimAddress' 2 0 Z City: '� it Zip; Facility Contact-Person: Conttset Phone No,*. Makc:Nodei of Monitoring System: Date of-resdnaorvicing: / B. XnyentsDry of Equipment Tested/Certi:aed Cheek thea rc rtateAetag to indicateeldric ui mint ins aetadJservieed; Tank ID:1' a Tank ID: 5L z 2.1in-Tank Gauging Probe. Modal: Q In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Modcl: ❑ Annular Space of Vault Sensor. Model: Piping Sump I Trench Sensor(s). Model: "Pipin® Sump l Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Q Fill Sump 5ensoQs). Model: V,MeeiisMlcal Line Leak Detector. Model:Mechanical Line Leak Detector. Model: ❑ Electronic Linc Lack Deceesor, Model: Q Eleetmnie Line Leak Detector. Model: 0 Tank, OverfIl I High•Lcvei Sensor, Model: D Tank Overfill / High-L.eve1 Sensor. Model: Q Other (specify ii menti a and model in Section E on Paas 2).+ Q Other (s ea ua ment tY a and aza0del in SeetioM Bun Pa„e 21, Tank ID; f Tansy Iii: D In-Tan% Gaining Probe, )4odal: ❑ in-lank Gauging Prpbc. - Model: Annular Space or Vault Sensor. Model: �' fy/ Z" ❑ Annutor Spoed or Vault Sensor. ' Model: Piping Sump / Trench Sensor(s), Model: ` ' Z 0 Pipin® Sump/ Trench SensorW. Model: 0 Fit Sump Sepsor(s). Modal. Q Fill Situp Sensar(s). Model: Mechanical Line L oak Detector. Model: �'' Wa 1� C3 i•9achanieal Lane Leak Decatur. Model: ' Q Electronic Line Leak Detector. Model: 0 Elaarogie Line Leak Detector. Model• 0 Tank Overfill I Wt.h-Love! Senior. Madel: 0 Tank Overfill I High-Level Sensor. Model; ❑ Other (s cifv ui mcnt type and model in Section E on Pare 2). ❑ Other (s ecifv EBWEECDCWPC and model in Section E on Pace 4 Dispenser M: -- % ,..,,._,... Di er ID; (a Dispenser Containment Scnsor(s). Model: _ Dispenser Containmcntt Serasor(s). Model: Shear Valvc(s). Sheat' Valve(s), . this enserComainmcnt Fioaa{s)'snd Chain(a) ` °" Des enseFContainr,%ns Fid'st('s) and Cliiin(s)." DispanscrID: ]�ispeaasorlD: ❑ Dispanser Containment Sensor(s). Model: Dispenser Contain=nt Sensor(s). Model:- ' Shear Valve($). ,Shear Valve(S). EMS engcr Containment Flootfs) and Chainrs). DispenserConWnment Floar(a) and Chain(s). Dispenser ID: Dispenser M: Cl Dispenser Containment Smsor(s). Model: ❑ Dispenser Containment Sensor(s), Model: f ❑ Shear Valve(&), O Shear Valve(&). r ❑Din enser Containment F1oat(sl and Chain(s). ❑ Dis enser Containment Flou(s) and Chain(s). 'If the facility contains more tanks or dispensers, copy this fonts, Include infamadon for every tank and dispenser at the facility, C. Certification . I certify that the ttlulpment ideptiiled in chis docuatent. was inspected/serviced in accordant with the rrt n-4gturors' Suldelines. Attached to this Cerdacation is inf0r=1S0n (ag. m=ufacmrers' eheekAsts) necessary to v" that this infarnnadon 35 correct and a Plot Plan showing the layout of manlzodngpn=c. For tiny equipment capable of Senamting such reports, I have also attached a copy of the report; (;ed cid that apply): System set-tap W history report Technician Naine (print): J®r,_ _ hri CALLtanD Sine.Eure! s Certifsc:adon No.; , �''` 7 License, No.: --J a44 84 Tcsdnj Company Name: f Phone Site Address: Date of Tessin@ ervicin - r page 1 of 3 Monitoring System Certification A3/dl