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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Coder 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: Roshan Valero Service Station No.: Site Address: 2420 Grant Line Rd City: Tracy Zip: Facility Contact Person: Roshan Minhas Contact Phone No.: 209-832-8273 Make/Model of Monitoring System: ��/,� ' -.� -1s2 r Date of Testing/Service: B. Inventory of Equipment Tested/Certified Check the apprTriate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: Tank ID: On-Tank Probe: Model: Mit-Tank Gauging Pro e: Model: e 0 QAnnular Space or Vault Sensor: Model ,4y31 a- yA62 ❑Annular Space or Vault Sensor Model: Mping Sump/Trench Sensor(s): Model: W=,t- ;.2c6 ' ENNping Sump/Trench Sensor(s): Model: Z 43c'0 d ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: EII�Acchanical Line Leak Detector. Model: n QMechanical Line Leak Detector. Model 447 2,V67v ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank OverfiliN igh-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, Smalf suiz and model in Section E on Pae 2 ❑Other, S ui . and model in Section E on Pae 2 Tank ID: Tank ID: TA-Tank Gauging Probe: Model: /' 7. y ❑In-Tank Gauging Probe: Model: @'Annular Space or Vault Sensor: Model: 7.9v3jo_ ❑Annular Space or Vault Sensor Model: ❑Piping Sump/Trench Sensor(s): Model: c?3 ❑Piping Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: (Mechanical Line Leak Detector. Model: Z []Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/Mgh-level Sensor: Model: ❑Other, S fui . and model in Section E on Pae 2 ❑Other, Specffy Speceguip. type and model in Section E on Pa e 2 Dispenser ID: —2 Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: lWShear Valve(s). VKhear Valve(s). UWi nscr Containment Float(s)and Chains) Mis nser Containment Float(s)and Cham(s) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: f'Sbear Valve(s). ❑ Shear Valve(s). EWispenser Containment Float(s)and Chain(s) ODispenser Containment Float s)and Cham(s) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: &9hear Valve(s). ❑ Shear Valve(s). UWispenser Containment Float(s)and Cham(s) 013ispenser Containment Float(s)and Chains) *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at this 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 equipmeyt capable of generating such reports,I have also attached a copy of the report; (check all that apply): fB System Sete army to report Technician Name(Print): Keith Huston Signature: Certification No.: e�,�r 4 G g^x-2. 7 License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (916)927-1557 Pacer 1 of.3 nasal