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MONI'V PRING SYSTEM CERTIF;�ATION ' For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code;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 sy&11ms widiut 30 days of test date. A. General Information Facility Name: ICd-S+ ar,e( tFasy MAit7- Bldg.No.: rn 1�^ Site Address: a44 NCr•d'vsc��t City: S+ockf-oA Zip�D� zi Facility Contact Person: Mf K z A L I Contact Phone No.: a1( Oy ) IF112 -899 _. Make/Model of Monitoring System: OminteC ZDEL 9000 Date of Testing/Servicing: S-A,-zZ 3rn^z p r B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: ()A )-G 0.d{d , � Tank ID: r G wl t'J M / [.t, In-Tank Gauging Probe. Model: r IT67 'F 2rin-Tank Gauging Probe. Model: M T-(rt-r (-'Anular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model:Rii,- t-W F (�iping Sump/Trench Sensor(s). Model: X-L� $Piping Sump/Trench Sensor(s). Model: RX-L 5—Ai. ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: L"echanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: O Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specia a ui ment type and model in Section E on Pae 2). ❑ Other(specia equipment t e and model in Section E on Pae 2), Tank ID: Tan ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or It Sensor. Model: ❑ Piping Sump/Trench Sensor(s). el: ❑ Piping Sump/Trench�S2nspr(s). Model: • Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). � Model: ❑ Mechanical Line Le ector. Model: ❑ Mechanical Line Leak Detector. Model ❑ Electronic Li ak Detector. Model: ❑ Electronic Line Leak Detector. Model: 13 Tan ill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ME er(s eci a ui mine t e and model in Section E on Page 2). ❑ Other(specia a ui ment a and model in Section E on Page 2 .� Dispenser ID: Z Dispenser ID: -3 ( )Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). .9'�hear Valve(s). ,,�/Di5 enser Containment Float(s)and Chains . $Dispenser Containment Float(s)and Chain(s). Dispenser ID: user ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Disp Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve LDispenser is enser Containment Floats and m s). ❑ Dispenser Containm loat(s)and Chain (s). ID: Dispenser ID: Dispenser Con inm nt Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Modekhe e(s). ❑ Shear Valve(s). �s enser Containment Float(s)and Chain (s). ❑ Dis enser Containment Floats and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include information for every 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 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 equipme t capable of generating such reports,1 have also attached a copy of the report; (check all that apply): ( )System set-up ( Alarm history report Technician Name(print): LEE A. WILLIAMS Signature: , Certification No.: S� I t7d- b y e 1 License.No.: 03160 Testing Company Name: Stockton Service Station Eauioment Co.,Inc. Phone No.:(209)464-8333 Site Address: JUIN k4rrJ rt,= tai q Date of Testing/Servicing: SV/GLC, 3 Page 1 of 0310I Monitoring System Certification