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# 5 <br /> 1-15-03; 2:31 PM:SaC rOmentO EMC ;916 9252816 2/� 'I <br /> MONI ORINGdictISYSaliforni <br /> For Use by Ali nTEMICER theState <br /> aTInCGATIION <br /> Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,California Code of Regulations <br /> This form must be used to document testing and servicing of monitoring equipment.A Sepsme certification or report most be prepared for each monitoring system control <br /> panel <br /> by <br /> the local agencwho y regulating g UST systems wishing 30 rays form must be <br /> test date.provided m the Tank system owner Operator. The own mopemwr must submit a copy of this <br /> focus f <br /> L <br /> ame Tracey Maintenance Station PG&E 1197 Bldg No. <br /> yess: 24081 Mountain House Parkway City: Trac ontact Person: Michelle Contact Phone No.: 209.935-1983 <br /> odel of Monitoring System: LA-04 82634 <br /> Daze of Testing/Servicing: 11-27.02 <br /> B. Inventory of Equipment Tested/Certified <br /> beck <br /> Tank ID: Unleaded (87) <br /> Model Tank ID: Diesel Model <br /> X in-Tank Gauging Probe (ES X In-Tank Gauging Probe (B) <br /> A LALS-1 X Annular Space or,Vault Sensor (A) LATS-1 <br /> X Annular Space or Vault Sensor ( ) <br /> X piping Sump/Trench Senaor(s) (P) LAISd <br /> X Piping Sump/Touch Srasor(s7 (P) LAIS-1 '.,. <br /> (H) Fin Sung Seraor(s) (M <br /> Fill SuaP se-ons) <br /> Mechanical Lute leak Detector (M) Mechanical Line leak Detecmr (M) <br /> Electronic Line Leak Detector (E} Eluuoruc Lim Leak Detector (E) <br /> Tank Overfill(High.levcI Sensor (T) Tank Overfill/High-level Sensor (r) <br /> Other(specify equipment type and model in Section E on Oder(specify equipment type and andel In Section E on <br /> Page 2 Page 2) <br /> Model Tank ID'. Model <br /> Tank to: <br /> >o-Tank Gauging Probe ($) <br /> Iu-Tank Gauging Probe (E) <br /> Annular Space or Vault Sensor (A) Annular Space or Vault Sensor (A) <br /> Piping Sump/Trench Semor(s) (P) Piping Sam I Trench Semor(s) (P) <br /> Fill Sump Semor(s) (H) Fill SumPSensor(s) (11) <br /> Mechsnical Line Leak Detector (M) Mechanical Line leak Dentia (M) <br /> Electronic tae Leak Detector (E) Electronic Line Leak Detemor (E) <br /> Tank overfilt/High-level Sensor (T) Tank Overfilylligh4evel Sensor (T) <br /> Other(spo ify equipment type and model in Section E on other(specify equipment type and model in Section E on <br /> Page 2) Page 2) <br /> Model <br /> Dispenser <br /> Model Dispenser to <br /> ID <br /> Dispenser Containment Senser(s) Dlspemer Containment Semer(s) <br /> Shear Valves) Shear Valve(s) <br /> Disperser Containment Flmt(s)and Chaira(s) Disperser Containment Fbai(s)and Chains(s) <br /> tyonel Dispenser ID <br /> Monet <br /> Dispensu lD <br /> DispenserConuinrrent Semu(s) <br /> Disperser Containment Semar(s) <br /> Shear Vnlve(s) <br /> She valve(s) <br /> Dispenser Conuinsrent Hoet(s)and Chaim(s) Dispenser Containment Float(s)and Chaitn(s) <br /> C. Certification-1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines. Attached to <br /> this Cenificatim is information(og:manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of <br /> monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the(check all that apply): <br /> System set-up report(attached) Alarm history report(aoacked) <br /> Technician Name Gene Babineaux Signature:LJpAW l�a�timo.Geus <br /> Certificate 02-0288 Contractors License No.:502377 <br /> Testing Company Name:Sacramento Equipmen tMaintemmce Nompaany pdInc. Phone No. 916-925-2716 Work Order#110002 <br /> 03101 <br />