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f MONIARING SYSTEM CERT11FRATION For Use By All Jurisdictions Within the State of Califomia 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 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: MCI Bldg.No: Site Address: 2551 E. Louise City: Manteca Zip: Facility Contact Person: Phone: Fax: Make/Model of Monitoring System: EBW Auto-Stik Date of Testing/Servicing: 11/1/2005 B. Inventory of Equipment Test/Certified Check the!22MLnate boxes to indicatespecific equipment ins ted/serviced: Tank ID: Dsl. Gen.Tank Tank ID: 1x In-Tank Gauging Probe. odel: M In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: EBW Annular Space or Vault Sensor. Model: X1Piping Sump/Trench Sensor(s). Model: EBW Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Lane Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Tank Overfill/High Level Sensor. Model: OPW 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: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line leak Detector. Model: Mechanical Line Leak Detector. Model: IHElectronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 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) Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenses Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). *If the facility contains more thanks 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,I have also attached a copy of the report;(check all that apply): _System set-up _Alarm history report t Technician Name(print): Dave Walker Sipna e• Certification No.: 006-05-0173 icense No.: 745065 A,B-Haz Testing Company Name: Tank Specialists of California a one No.: (909)273-0900 Facility Address: 1379 Pico St., #103, Corona, CAW8$1.__ u•s•T Date of Testing/Servicing: 11/1/2005 Monitoring System Certification Page 1 of 3 l J 03/01 MCI-Lodi mon.cert.11-01-05.xls G IF®��®