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10-21-'14 13:51 FROM- West Star Envmt Inc. +559-277-0106 T-439 P0002/0006 F-010 MONIRING SYSTEM CEIiTIFICOTION Por se By All Jurisdictions Within the State of Califf ornia 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 f r each. monitoring system control panel by the technician who perforans 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: Bldg.No.: Site Address: '5091 City: Zip; 01 S,D 1p Facility Contact Person: 9N A\)jVj-¢.f al_,-_s, Contact Phone No.: ( ) 19 ` — 7 Make/Model of Monitoring System: L,--> -:3w, Date of Testing/Servicing: t-{ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment in�ecte_dlservccd: 7 Tank TD: g Tank ID: 7! ❑In-Tank Gauging Probe. Model: ❑Ln-Tank Gauging Robe. Model: `Annular Space or Vault Sensor. Model: JWAnnular Spade or Vault sensor. Model: Ue "Piping Sump/Trench Sensor(s). Model: gPiping Sump/Tieach Sensm(s). Model: —76 ❑Fill Sump Seasor(s), Model: ❑pili Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Cine Leak Detector. Model: ,Electronic Line Leak Detector. Model: Electronic tine Leak Detector. Model: Tank Overfill I High-Level Sensor. ModcL y44jWA- rank Overfill/High-Lcvd SOW Model• ❑Other(specify equipment type and modal in Section E on Page 2)- ❑Other(specay,equipment type and model m Section E on Page 2). Tank ID: 15V7 b Tank D): ❑In-Tank Gaugutg Robe. Mode: ❑in-Tank Gauging Probe. Model: 'IlAnnular Space or Vault Sensor Model: Annular Space or Vault Sensor. Model: Piping Sump I Trench Selum(s). Model: Jo ❑Piping Sump/Treach Sensor(s), Model: Fill Sump Sensor(s). Model: ❑Fill Sump Senso0). Model ❑Mechanical tine Leak Detector. Model: ❑Mechanical Lane Leak Detector. Model: <Electronic Line Leak Detector. Model: _ ❑Electronic Line Leak Detector, Model: Tank Overfill I High Level Sensor. Model: Tt-' ❑Tank OverFan/High-Level Seasor. Mallet: Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section G on Page 2). Dispenser ID: 42= DLspenser ID: ❑Dispenser Containment Sensor(s), Model: ❑DLapcnaer Ctmtsum ent Sensor(a). Model: Shear Valve(s). Shear Valve(s). am ispcnser Containment Float(&)and Chain(s). Disponaer Containment Floats)and Cha Dispenser ID: Dispenser M: r ` ❑Dispenser Containment Sensor(s). Model: ❑Diapenaer Contawnent Sensor{&). Model: Shear Valve(s). shear Valva(&). QCT 21 2014 Dispaiscr Containment Float(s)and Chain(&). Dispemser Containment Pleats)and Chaia(s). Dispenser 11); Dispenser ED: FM/IRONMENIALH LTH ❑Dispenser Contatnmcnt Senso(s). Modal: ❑Dispenser Containment Sensor(&). Model: —DL�"-a<rrrr$'A E NT ❑ Sheet-Valve(s). Q Shear Valve(s). ❑Dispenser Containment Float(&)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). vlf the facility contains more tanks or dispensers,copy this form. Include information for every lank 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 pment. Nor any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): kN System set-up Alarm historyrreport Technician Name(print): STEVEWILLEMS Signature: Certification No.: ;6 M7 License.No S/yx Testing Company Name: WEST STAR ENVIRONMENTAL, INC. Phone No.:(669) 277-9378 Testing Company Address: 4770 W.JENNIFER AVE., FRESNO, CA 93722 Date of Testing/Servicing: ) Page 1 of 3 Rev(2108)