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/IONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6 Z Health and Sgfery Code:Chapter 16, Divisinn 3, Title 23, California Code of Regulaiiom This form must be used to document testing and servicing of monitoring equipment.A scnarate certification or resort must be prepared for=It 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. USA PETROLEUM 110 A. General Information 2132 MARIPOSA RD. Facility Name: STOCKTON, CA 95205 _ Bldg.No.: Site Address: Zip: Facility Contact Person: // � rr -may r Contact Phone No.:(_) Make4'Model of Monitoring Svsrem:_ 1'Awe-1tf4.. /�� ✓�. � Date of TesRng/Servicing' - l_/ B. Inventory of Equipment Tested/Certified Check thi.pppriiile boxes to indi Le re uimint" wied/sermed: atilt ID: Tank ID: cJ_ -Tank Gauging Probe. Model: AIA4 lfn-Tank Gauging Probe. Mode alar Spare or Vault Sensor. Model: Waaa0uler Space or Vault Sensor. Model: ing Sump/Trench Sensor(s). Model: ZWping Sump/Trench Seasor(s). Madel: Q Fill Sump Scnsor(s)- M(ulel: ll Sump Sensoria). Modal: SMedianical Line teak Detector. Model:F Ll Fill 9AMechmical tine Leak Detector. Model: — 0 E)ecuonic line teak Detector. Model: � ❑ P3ceuome Line Leak Detector- Model: ,.Sank Overfill r High-Level Sensor. Model: .21Q`ank Overfill l High-Level Sensor. Model: ❑ Other(s iN ui t t and nxxie7 is Section E on Page 2). Q Other(Specify equipment and mode!in Section E on Pue 2). Tank ID: Tank ID: -Tank Gauging Probe. Model: Tank Gauging Probe. Model: War Space or Vault Sensor. Moded: ular Space or Vault Sensor. Madel: rpiug Suaw/Trench Sensor(s). Model: 16121ping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s). mom,—�,—r ,-- VeMechanical Line Leak Detector. Model: — AMeclianical tine Leak Detector. Model: t"C i7 E)ccuonic Lane Leak Deroctor. Model: D Electronic Line Leak Detector. Model: ink Overfill/Agh-Level Sensor. ModeL Tank Overfill/Nigb-Level Sensor. Model, Q Other t and model in Section E on Page 2). Q othrr(s ui and model in Section E oa Page 2). Dispenser ID: - Dispenser ID: -- `A-9ispenserContainment Sensor(s). Moder ispcnsa Containment Sensar(s)- Model: $$hear Valve(s). Shear Valve(&). O Dia sar Contamnent Floats and Cham(s). Q Disperser Containment Fla s and Chain(s). Dispenser ID: — Dispenser ID: *kDispenscr Containment Smsor(s). Model: $13ispenser Containment Sensor(s). Model: S$haar Valva(s). 23-Shear valve(s). ❑ Dispenser Cort a rma:dT Fl )and Cham(s)- ❑ Dispenser Containment Floats and Chain(s). Dispemer ID: Dispenser ID: 1J9�tspensv Comaioment Sensor(s). Madel: 5kBispeoser Containment Setuor(s). Model: S�SKear Valve(s). ,@Shear Valve(s). QL)i ser Containmwc FoaUs)and C3rain s). El Di&pimier Containment Floats and Chaio(s). -If the facility contaias more tanks or dispensers,copy this form. include information for every tank and dispenser at the facility. C. Certification-I certify that the equipment identifted in this document was mspected/servicad in accordance with the manufacturers' grdddinas. Attached to this Certification is information (e.g,ln3attfacnurn' checklists v' the layout of monitoring ) °g'ffi'yn ar"r(Y that this information is correct and a Plot Plan show m8 Y g a4niPmrm For any a of era such attached a m of the re it;(check all Nmt t g reports,I have also PY apP Y)� �8alem set-up m ' Technician Name(print): h Ne LMC d e Signature:nse. �e -y s _Z=� Certification No.: LiceNo., Gfi.) Testing Company /y _{Phone Site Address: DnNe oof.:�Te�atiOagl/Se}rvicing:��'sL/ Page 1 of 3 03101 Monitoring System Certification