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INIONITQRING SYSTEM CERTMICAT ION or Use By All Jurisdkiions Within. the Stare of CaWomia Authority Cited: Chapter 8:7. Health and Sgfery Code: Chapter 16, Division 3, Title 23, California Code of Reguladom This form mnst'be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring systemcmc ntrol panel by the technician,vho perforans the work_ A copy of this form trust 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 Inform Facility Name: SOUTH BAY TIRE 1501 W. CHARTER WAY SiteAddrass; STOCKTON, CA 95206 Bldg. No.: Zip: Facility Contact Person: Make/Mcdel of Monitoring System: .2s s /DCC „�/�J\D� Date of Testing/Servicing: I 7 I Q t" B. Inventory of Equipment Tested/Certified Check thea ro 'ate tex to indicate tai trent ected/serviced: Tank ID: T..Pk ID: 241 -Tank Gauging Probe. ' Mo(1el: Probe. Model: )R nnuta Space or Vault Sensor. Model: - 1�2-TankGauging ular Space or Vault Sensor. Model: b;zPiping Sump I Trench Semsor(s) Model: - . �k� -, Piping Sump / Tench Sensor(s). Model: Q Fill Sump Sensor(s). U49redianical Line Lzak Detector. Model: .c Model: _ � ❑ Fill Sump Sensor(s). salient Line Leak Detector. Model: Model: 0 EleatonicLineLeakDeuettor. Model: Li Eiccuoaiclint Leak Detector. Model: wank overfill I Ffigh-Level Sensor. Model: - "C ^w>qrfark Overfill I High -Level Sensor. Model: 0 Other (specify equipment type and model:ia Section E on Page_3), Q Odrer (specify equipment type and model in Tank ID• 0 in -Tank Gauging Probe. Model: 0 Annular Space or V salt Sensor. Model: Q Piping Sump / Trench Sensor(s). Model. "Ir - 0., Cl Fill Sump Sensor(s). Model: Q Mechanical Line Leak Detector. Model: Q Electronic Line Leah Detector. Model: Q Tank Overfill I High -Level Sensor. Model: Q Other (specify equipment type and model in Section E on Parte 2). Dispenser LD: (- e_-_ 0 Dispenser Containment Sensor(s). Model: 'E i*hear Valve(s). Tank M: 0 fn -Tank Gauging ire. Q Annular Space or Vault Sensor. Q Piping Sump / Trench Sensor(s). Q Fill Sump Sensor(s). Q Mechanical Line Lzttk Detector. Q Blectronfc Line Leak Detector. 13 Tank Overfill / High -Level Sensor Q Other (specify equipment type and Dispenaw ID: — 0 Dispstser Cant Shear Valve(s). Model: Model• Model: Model: Model: Model: Model— > - If Scnatr(s). Model: and Dispenser ID: T "' Dispenser ID: Q Dispenser Containment Setor(s). Model: Q Dispenser Containment gea=(s). Model: bear Valve(s). shear ValYe(s) tel?; user Containment Float(s) and h(s) ❑ Dis[?ensra' Containment Floatfs) and Chain(s)- Dispenser ID: Q Dispenser Containment Shear Valve(s). and Model: Q Dispenser Containment.Settsor(s). Model. 0 Shear Valve(s). 12 Ditnetcs w Cmntainsnrrt I:enu0c1 -4 f`I,�:. (A facility contains more tanks or dispensers, copy this form, include information for every tank and dispenser at the facility. C. Certification -I certify tm the equipmeatuentified in this document was inspected/servked In accordance with the manufacturers, guidelines. Attached to this CeriMcation Is information (eg. mannifaenuew checklists) u9cen=7 to verify that this information Is correct and a Plot Pian showing the layout of monitoring equipment. For any equd ca a generating such reports, i have also attacked a copy of the tepory (check all the apply): Q System set-up Q Technician Name (print): (`' Ob N e-i-ry) e -,A e- g Certification No.: License No.: WG Testing Company Name: Phone No.:{ 7b'% } y ('Q Site Address: 50 1 w ' C-6' i yl -LA CA— � 0..e d i p lr _ Date of Testing/Servicing: -7-J—Z—/J4 ]'age 1' of 03101 Monitoring System Certification