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DEC-30-2008 10 :42 AM GETTLER—RYAN INC. 925 551 4770 P. 03 MONITORING SYSTEM CERTIFICATION For Use 13v,411.1ur4sdict1onr Within the.State ofCal(fornia authority Cited: Chapter 6.7, Health and Safeq,Code; Chapter 76, Division 3, Title 3. California(..'ode of Regulations This form must he used t0 document testing and servicing of monitoring equipment. nc�a_rp,iL GCiil�p-ALjg11,..gLgRoi(Sr1NdIh1<PL@Pared for„ggkq monitoring systcm uun,{rQl nartel by the technician who performs the work. A copy of this form must he provided to Me tank system owner�opmat(r. The owner/operator must submit a copy of this form to the Incas agency regulating UST systems within 30 days of test date. A. General Information Facility Name: _ r. — —__ Bldg. No.: Site Address: ��`L� lc�: s ..� -- City c��e` k o ` - &): Facility Contact Person: id 4- _.._. -------.---------- Contact Phone No.: Make/Model of Monitoring System: .'r�5_ ; cL"___—_.—_.__-,.__,- _____ Date of Testing Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced: Tank ID: Tank II): • ,I y�- 51In•TankGauging probe. Model: jjt&j2t'71.7jefa In-Tank Unuging Probe. Mocict. 139 An 9 Annular Spa"or Vault Sensor. Model: _ (� nular Space or Vault Scmor. Modem �� Piping Sump/Trench Sensor(s). Model: � ®Piping Sump t ITench Sermons). Model. ❑Fill Sump Simsotts). Model'. ❑rill Sump Senmr(0 Model: ❑Mechanical Line Lzak Detector. Model: ❑Mechanical Linc Lcak Detector. Model: _ Electronic Linc Leak Detector. Model: t' ', / [KElearome lane Leak Delectm, Model, Zx ❑Tank Overfill/High-Level Sensor. Model. _ ❑ rank Overfill/fd igh-Level Scusot Model. ❑Other(specify equipment type and model in Section Fi on Page 2), ❑Other(specifv equipment typo and model in Section E on Page 2). Tank ID: U_s O:..STank ID: ❑In-Tank Gauging Probe. Model. ❑In-rank gauging Probe ModeP,J_�_ ,Annular Spacc or Vault Sensor, Model: L/zo ❑Annular Space or Vault Sen5or. Model ®Piping Sump/Trench Sensora). Model. L4Yg' ❑Piping.Sump'Trench Senson s). Madel: ❑Fill Sump Sensor(®). Model: ❑Fill Sump Sensor(s 1. Model, ❑Mechanical Linc Lcak Detector. Mudcl: ❑Mechanical Line Lcak Detector. Modeh _ ❑Electronic Line Leak Detector. Model. ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Scnsor. Model ❑Tank Ovcrtill%1ligh-Level Sensor, Model: ❑Other(specify equipment type and model in Section Eon Page 2). ❑Other(specify equipment type and model in Section F on Page 2). Dispenser ID: i 0 Dispenser ID' I Li A P'Ssc pv _W ®Dispenser Containment Semor(s). Model 2.0 C aDispenso (ontainment Sensons). Model: Q Shear Valve(®). JA Shcar Valve(:.). Ed Dispenser Containment Float(a)and Chain(s). Q Dispenser Containment Floats)and Chainls). Dispenser ID: Z— (j (r—_x, d Dispenser ID: IM N5puiser Containment Sensor(s). Model: j_GY 2r ❑Dispenser Containment Sensor(i), Madel. ®Shear Valve(s). j ❑shear Valve(s). (il Dispenser Conlainmem Float(s)and Chain(s). ❑Dispenser Containment Floaus)and Chain(s). Dispenser IDD Dispenser ID: ❑Dispm cr Containment Senter(s) Model: — ❑Dispenser Containment Sensor(s). Model. ❑Shear Valve(s). ❑Sheer ❑Dispenser Containment Floats)and Chain(®). ❑Dispenser Containment Floats)and Chain(®). *If the tltoility contains more tanks or dispensers.copy this firm. Include information for a very tank 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 U information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the[layout of monitoring equlpment. For any equipment capable of generating such reports,]have also attached n copy of the report; (check oil than apply): ®System set-up Alarm history report Technician Name(print): L.,e,.s .f".L_.! t•., ., Signature: —.._..�— Cenification No.: 7 frS'S?__ 11 —_ License.No., Testing Company Name' —�( �� l- rte. _,_----_..___ Phone No.: festing Company Address: Date of Testing Berviutw 1/�ZSD PW t of 31 Acv(res)