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AF—ORDA—TE$T 12097940112 P. 06 `e/ \"No, MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of CaVornia Awhortry Cited: Chapter 6-7,Ilealth and Safety Code;Chapter 16,Division 3, I'tlle 23, California Code of Regulations This form nmst be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepare[. for each monitoring system control panel by the technician who performs the work. A copy of this form toust be provided to the tam system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 3• days of test date. A. General Information Facility Name: y M A R7` Bldg.No.: Site Address: ,�Yy H ar(�,n� w o+( City: o n Zip Facility Contact Person: m ' e Fl LI Contact Phone No.: Make/Model of Monitoring System: Orta j A to e �EL 000o Date of Testing/Servicing:ti S-/6-d 3 B. Inventory of Equipment Tested/Certified Check tht RPPr0PFlattb0XtS to indicates ecifc a ui mens ins ted/serviced: TanklD: Oill-cad-ed Tank ID: Proe M1,tjM ✓In•Tank Gauging Probe. Model:�_'�lTl'77 -F Q7n-Tank Gauging Probe. M1401: [del:, m 1-67 IT Space or Vault Sensor. Model: 9�Annular Space or Vault Sensor. M[del: rt L W f= (piping Sump/french Sensor(s). Model:i s Id-Piping Sump/Trench Sensor(s). Mdel: Htc-L S-Aft Q Fill Sump Scosor(s). Model: Cl Fill Sump Sensor(s). M emechanioal Line Leak Detector. Model: .0'Mechanical Line Leak Detector. Ni del: Q Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector, Mdcl: Q Tank Overlill/Iligh-Level Sensor. Model: Cl Tank Overfill/High-Level Sensor. Model: Other(specify ui mens type and model in Section E on Pae 2), Q Others ci tri mens a and model in$edl0n E on Page 2), TankiO• Tan Q In-Tank Gauging Probe. Model: Q In-Tank Probe. M'del: ❑ Annular Space or Vault Sensor. Model Q Annular Space or It Srnsor. Mdel: Q Piping Sump/Trench Sensor(s). el: (] Piping Sump/Trench r(5). Madel: O Fill Sump Scitso""' Model: O Fill Sump Sensor(s). Model: ❑ Mechanical Linc!xa cctor. Model: Q Mechanical Line Leek Detector, edel• ❑ Electronic L' k Detector. Model: Q Electronic Line Leak Detector. Model'- _ ❑ Tao r di/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Mudek er Uecify equiemont!ac mid model in Section E on Page 2), Q Other s cci ui mens a and modol in Section E on Page h., Dispenser ID_„ Z Dispenser ID: 3/ y ( )Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Model: 4KShear Valve(s). .0'�Jhear Valve(s). Z`bispenser Containment Floats and Chain(s). $•Dis ser Containment Float(s)and Chnin(s). Dispenser ID: user ID: Q Dispenser Containment Sensor(s). Model: ❑ Disp Containment SrnSor(5). Model: Q Shear Valve(s), Cl Shear Valv Q Dispenser Containment Floats and n s. Q Dispenser Contaitun lost s and Ch dri(s). Dispenser 11) : Dispenser ID: ❑ Dispenser Con m nt Sensot(s). Model: ❑ Dispenser Containment Senso s). Monk. Q Shc e(s). Q Shear Valve(s).Loo is user Containment Floats and Cbain s. Q Dispenser Containment Floa s and Chiin(s). *If the facility contains more tanks or dispensers,copy this form. Include infoimation for every tank and dispenser at th.: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 equipm t capable of generating such reports,I have also attached a copy of the report;(check all that appty): ( )System set-up (t�htrm history report: Technician Name(print): LEE A.WILLIAMS Signature: Certification No.; S7 109 O yf5 0( License.No.: 03160 Testing Company Name:Stockton Service Station Equipment Co Inc. Phone No.:(209)464-8333 Site Address: Arlt( 1/0,rd rhe A„j Date of Testing/Servicing.: S / C>3 Page 100 3 Monitoring System Certification 03/01