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P, Tanknok)gy NITORING SYSTEM CERTIFICATION F e By All Jurisdictions Within the State of Califomi Authority Cited: Chapter 6.7, Hea th and Safety Code; Chapter 16, Division 3 Title 23, C omia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, a separate certification or report must be prepared for each monitoring system control panel 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: CANEPA CAR WASH Site Address: 642 N HUNTER Facility Contact Person: PAUL CANEPA Make/Model of Monitoring System: TLS -350 B. Inventory of Equipment Tested/Certified City: STOCKTON Contact Phone No: 948-1636 Date of Testing/Service: 06/11/2002 Work Order Number: 2222546 Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95202 Tank ID: 91 Tank ID: 87-# 1 X In -Tank Gauging Probe. Model: MAG 1 X In -Tank Gauging Probe. Model: MAG 1 X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: 420 X Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 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: W.P.L.L.D X Electronic Line Leak Detector. Model: W.P.L.L.D 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 (specify equipment type and model in Section E on page 2). Tank ID: Tank ID: DIESEL X In -Tank Gauging Probe. Model: MAG 1 In -Tank Gauging Probe. Model:' X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: 420 X Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: MANIFOLD 87 # 1. Electronic Line Leak Detector. Model: W.P.L.L.D Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other (specify equipment type and model in Section E on page 2). Otheri equipment type and model in Section E on page 2). (spec'fy Dispenser : 1.2 Dispenser ID: 7.8 X❑ Dispenser Containment Sensor(s) Model: STANDALONE :xj Dispenser Containment Sensor(s) Model: STANDALONE ® Shear Valve(s). Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3,4 Dispenser ID: 9,10 X❑ Dispenser Containment Sensor(s) Model: STANDALONE 71 Dispenser Containment Sensor(s). Model: STANDALONE Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5,6 Dispenser ID: 11,12 ® Dispenser Containment Sensor(s) Model: STANDALONE X Dispenser Containment Sensor(s). Model: STANDALONE Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) 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 1 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the (Check all that apply): System set-up report; ® Alarm history report ® / PRINTED NAME.KEITH ROWAN SIGNATURE: 4,� COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 03/01