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12/09/2005 13:21 7075770586 STROUPE PETROLEUM PAGE 02/10 MONITORING SYSTEM CERTIFICATION TION 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 prgpared for each monito njk_SY9_te_M__C_0at__rQLDAne_1 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 . Facility Name; Bldg.No.: Site Address: City. b Zip; Zn77 Facility Contact Person: Contact Phone No.: (_'ZQC4 )H28-r35 Make/Model of Monitoring System:'Y L. Date of Testing/Servicing: 17._jqa/ B. Inventory of Equipment Tested/Certifted Check the approgriate boxes to indicatespecific equipmenti ected/serviced, Tank ID: Tank ID; E ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: �2Q ' M Annular S»aoe or Vault Sensor. Model: '" �►�.Cs Piping Sump/Trench.Sensor(s). Model: Cl Piping Sump/Trench Sensor(s). Model: .ES{ Fill Sump Model: til Fill Su:np Sonsor(s)-Avfty Model: =_3 2_o ❑ Mechanical Line Leak Detector. Model: 0 Mechanical Eine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Gl Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/sigh-Level Sensor. Model: ❑ Other s eci ui ment D2e and odel in Section E on Page 2). ❑ Other�'mix 29ui2meftt t e and model in Section E on P e 2). Tank ID: Tank IA: ❑ In-Tank Gauging Probe.1jModel: Q Iii-Tank Gauging Probe, Model: 0 Annular Space or Vault Sensor. Model: r 3ZQ 0 Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor($). Model: ❑ Piping Sump/Trench Sensor(s). Model: 91 Pili Sump Sensor(s).A 14` I Model: 2 d ❑ FilI Sump Serisor(s). Model: p Mechanical Line Leak Detector, Model; ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector, Model: _. .._ ❑ Tank Overfill/fth-Level Sensor, Model; ❑ Tacak Overfill/High-Level Sensor. Model: i ❑ Other,,(s2ecia a ui inent type and nxodel in Section E on Page 2), ❑ Other(specify a ua rpent=e and model in Section E on P e 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve($). ❑ Shear Valve(s). ❑ Dis ewer Containment Floats and Chains. D Dis nser Containment Float(s)and Chains . Dispenser ID: Dispenser II?:_ ❑ Dispenser Containment Sensor(s), Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Q Dispenser Contaimzient Floats and Chains . Q D' eraser Containment Floats and Chains . Dispenser ice: ro, spenser DD: ® Dispenser Containment Sensor(s). ,Model: Dispenser Containment Sensor(s), Model; E3 Shear Valve(s). Shear Valve(s). ❑Dim enser Containment Floats and 9hain r)- D' enser Containment Moatgs2 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 any equipment capable of generating such reports,ii have also attached a copy of the reEort;(check all that apply); /CSystem set-up ® larm hist ry r ort Technician Name(print): -. a.l7�.___.s _ _ Signature: Certification No.: No.: _Iq 538 Testing Company Name: �I Q M71 Phone No.:( ) '577- 230-7 73®7 Site Address: r[ �w't''ton Aoa - -- - ------- Date of Testing/Servicing'. /P4 UN-036-1/4 Page I of 3 Rev.06/04/01 www.uuidomorg