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r • • MO*ORING SYSTEM CERTOCATION 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 prepared for each monitoring system control panel by the technician who performs the work. A copy of this form mu ioe proved to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating+pJST sys�ms within 30 days of test date. A. General Information, Facility Name: � �kVVn ; Lry t Bldg. No.: = f, Site Address: % City: 15&0r, � fVrl Zi� -- Facility Contact Person: Contact Phone No.:Q14.q C�� Make/Model of Monitoring System: tCSW At/�S�tek ��. Date of Testing/Servicing: G 'e20 •-"' B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment incnerred/vr it i• Tank ID:_ Te-, c- Z Tank ID: /In -Tank Gauging Probe. Mod7l ot6W ( 0 $ l �0 Zr In -Tank Gauging Probe. Model: 7/40FRW /08 24, k jAnnular Space or Vault Sensor. Model: L. j -3 0 4} O'Annular Space or Vault Sensor. Model: L ,-/ Piping Sump / Trench Sensor(s). Model: 4.5-36, _-30,4 ZPiping Sump / Trench Sensor(s). Model: L 5 - ❑ Fill Sump Sensor(s). Model: _S _ ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: _ ❑ Mechanical Line Leak Detector. Model: _ C1 Electronic Line Leak Detector. Model: LJ Electronic Line Leak Detector. Model: _ ❑ Tank Overfill / High -Level Sensor. Model: _ ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment ty e and model in Section E on Pa e 2). _ ❑ Others eci a ui ment type and model in Section E on Page 2). Tank ID: ❑ In -Tank Gauging Probe. Model: Tank ing Probe. Model: ❑ Annular Space or Vault Sensor. Model: 7DAnnularSpace ault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). el: ing Sump / Trench or(s). Model:❑ Fill Sump Sensor(s). Model: Sump Sensor(s). Model: ❑ Mechanical Line etector. Model: ❑ Mechanical Line Leak Detecto:and ❑ Electronic eak Detector. Model: ❑ Electronic Line Leak Detector.Model: Cl Tank verfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level SeModel: either (s ecify equipment type and model in Section E on Pae 2). ❑ Other (specify equipment ty emodel in Section F on Page 2). Dispenser ID: 1/7- Dispenser ID: 31 Cf i (TDispenser Containment Sensor(s). Model: L{UG $e4.vdrswv R-DispenserContainment Sensor(s). Model: q 06 ea�dre�.0 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: $'/(v Dispenser ID: -7l8 0' Dispenser Containment Sensor(s). Model: YC) Qt aud4*t•-U a Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: wjxser ID: ❑ Dispenser Containment Sensors _ ❑ Dispenser s L_ r s . Model: ❑ Shear V ❑ Shear Valve(s). s enser Containment Float(s) and Chain(s). ❑Dis enser Containment Float(s) and Chain(s). the tacuny 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, 1 have also attached a copy of the report; (check all that apply): ( ) System set-up Alarm history report Technician Name (print): LEE A. WILLIAMS Signature: Certification No.:_ 3a 68 License. No.: 03160 Testing Company Name Site Address: Stockton Service Station Equipment Co. Inc. Phone No.:(209)464-8333 Date of Testing/Servicing: & `01,0 '03 Monitoring System Certification ORIGINAL MAILED TO: San Joaquin County Page I of 3 Environmental Health Div. Attn: Dennis Catenyag 304 E. Weber St., P Floor Stockton, CA 95202 03101