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MONITORING SYSTEM CERTIFICATTON <br />or Use By All Atrisdictions Within the Stare of CaWbmia <br />Authority Cited: Chapter 6.7. Health and Safety Code: Chapter 16, Division 3, 7-z* 23, California Code of Regulazions <br />This form must be used to document testing and servicing of monitoring equipment" A seyarato certification or retrort moss be prepared <br />for each monitorimg systere control genal by the technician urho performs the work. A copy of this form must be provided to the tank <br />system owner/operator. The ownertoperator must submit a copy of this form to the local agency regulating UST systems within 30 <br />days of test date. <br />A. General Inf USA PETROLEUM 835 <br />2705 COUNTRY CLUB BLVD. <br />Facilityl�iame: _.._ STOCKTON, CA 95204 Bldg. No.: <br />Site Address: Zip: <br />Facility Contact Person: Contact Phone No.: <br />Make/Model of Monitoring System o d- Date of Testing/Servicing:�— <br />B. Inventory of Equipment Test+e&Certified <br />C. Certif atioit -I certify that the Nuk=M NNOW in this document was inspemYseryked in amordsum with the manufacturers' <br />goiddines. Attadied to this CettiScado¢ is mfonnation (e g. ' dmddts s) neousary to veriitiy that this f1dormation is <br />correct and a Plot Pfau dowing the fayont ofAmontiodsg For may a 61da such reports, I have also <br />attached a copy of the ( ek d[ t aappty): ystent set-up into <br />Technician Name (print): � � *°� Signature:µ <br />Cer6ficaticm i�=o_: License_ No.: O�✓�%G✓ x <br />Testing Company Name: Phone N04 7-0 } " `'t t 2 <br />Site Address: Date of TestiugJSesvicing: <br />Page I of 3 03(01 <br />Monitoring System Certification <br />