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IFIC010N CERT California Code of R mONITORING SY, ►STIVithin the le Of California I Jurist di tion S!� 3. Title 23, Ca c For Use By Al ris and Safety Co�e; Chapter 16, Division Of r it must be or for ea—ch aracertifies Health s Ae -- to the tank sY 111 Authority Cited: chapter 6.7, . cing of monitoring equipment. is must provided ed to document testing and servicing e w cop Of SY within 6 days of test date. This form must be used e technician who P ulatin ENVI ONMLNTAL n_ion,Ltoring sysLe_mco jMj vane by th ', form to the local agency re Wr I I '=KIT The owner/operator must submit a copy of this A. General Informat'On City: ESIhnell Stocklon Facility Name: Site Address: 717 W. E71 ht hth St. Contact phone No.. Facility Contact person: owner -Joe Make/Model of Monitoring System: Vee erot TL 350 B. Inventory of Equip'nent TankID: #1 -Re Uiar Model: 8473901-109 In -Tank Gauging Probe. Model: 7943W302 Annular Space or Vault Sensor. Piping Sump I Trench Sensor(s). Model! _79438&�208 CEI Viol Sump Model. 79 -208 Mechanical Line Leak Detector. Model: V2p too, FXIV .❑ de Electronic Line Leak Detector- Model: Tank Overfill / High -Level Sensor' Model: ATG E] other (specify equipment type and model in Section F on Page NOEMM== Tank ID. Annular Space or Vault Sensor- Mel:79M'A 0 in -Tank Gauging Probe. Model: 1:147M I CD Annular Space or Vault Sensor. Model: §Plit LW JZ Piping Sump I Trench Scnsor(r). Model: 79431 Tank Overfill / High -Level Sensor' Fill Sump Sensor(s). Model: 79431 Mechanical Line Leak Detector. Model: V n Electronic Line Leak Detector. Model: 0 Tank Over Hil / High -Level Sensor. mooer ATa [] Other (specify equipment type and model in Sectio on Page Date of Testing/Servicing: Tank ID: 112'4-12_21125M ... In -Tank Gauging Probe. Model: 847390-1 Annular Space or Vault Sensor- Mel:79M'A Piping Sump / Trench Sensor(s). Model: I model-- Fill Sump SensoAs ). mecnant-A 1:4- L-A Detector.VMI LW n Electronic Line Leak Detector- Model: _ Tank Overfill / High -Level Sensor' Model: ATG model in Section I - ❑ Other (specify equipment type and In -Tank -Gauging probe- Mow; Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: 0 FIB Sump Sensor(s). Model: n Mechanical Line Leak Detector. Model: n Electronic Line LA* Detector. Model: [3 T." o-..-ru j mak 1 —.1 rZonear. UndPl' [I Other (specify equipment type and model in Section E -1 Page 2). Dispenser ID: 4-4 Dispenser ID: 1- 2. Sensor(s). Model: 7943M LoDispenser Containment Sensor(s). Model: 794380-208 0 Dispenser Containment S [0RhPqr VnIvP.(Q) Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ED: 7-8 [Q Dispenser Containment Sensor(s). Model: 794380-208 0 Dispenser Containment Sensor(s). Model: 794380-20B Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID. 0 DispenNcr Containment Scnsor(s). Modcl. 794380-208 ED Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this Dispenser TD. 0 Dispenser Containment Sensor(s). Model. 7 JD Shear Valve(s). El Dispenser Containment Hoat(s) and Chain(s). Include information for every tank and dispenser at the j' C. Cer6fication - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is info tion (e.g. manufacturers' checklists) necessary to verify that i'*s information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such , !1eports, I have also attached a copy of the report; (check all that apply)-., Ej System set-up Alarm history report Technician Name (print): Jeff Certification No.: A22219 Testing Company Name: Pinnacle Fuel Testing Company Address: Signature: _ License. No,: � 1801782 UT CSL Phone No.: (408) 206-9840 115152-2849 Date of Testing/Servicing: lIL2015 M'W