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MONITORING SYSTEM CERTIFICATION For Use by All Jurisdictions Wthin the Slate of Ca;;fornia Authority Cited: Chapfer 6.7, wealth and Sajety Code; Chapter 16, Division 3, Title 23, California Code of ReZJation5 This form must be used to document testing and servicing of monitoring equipment. A separate certification or ieport 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 tliis form to the local agency regulating UST systems within 30 days of test date, A. General Information Facility Name: SP PRODUCTS COMPANY '-Service StationNo_: 15469 _ Site Address: 130 S WILSON WAY Citg: STOCKTON Zip: 195205 Facility C ontact P ers arse Contact Phone >� o : 5�2 - S -`� `7 Make/Model ofl+llonitoringSystam_ �1-�it"3 .Date of Test.ng/Sezvice: B. Inventory of Equipment Tested/Certified Cluck the 2pprTri2te boxes to indicate eific e ° meni ected/seniced: Tank DankClnu Probe: Model: (D� T In-Tame • Gauging Probe: --� Model: rinulnrSpnce orVaitltSensox: Model: 0- G Annular_pece orVaultSensor_ Model: Sum 1T'renchSensors : Model-ju _ ipmgSumE7renchSens orgsL Model ; -32 Model S/G^ al Sump Sensor(:):._Model. : p —echanicalLine Leak Detector. Model: MechanicalLine Leak Detector, ! Model: ect.r.e Line Leak Detectorg_ Model: Etronic t-ine Leak Detector -Modl Model:i u:h Model '+ W69/ -DD f then, Specify equip. type and model inSection E on P e 2 et'. ec' a ui , t e and model in Section E on Pa e Z Tank ID: 7 I Tank ID: i _... n-Tankd_au • Probe: Model: `' ( 6 a.In TarikGaugingProbe: Model: ......... ---... _ _fig-- - _ .:�- - -- ---... _ _ ------ -.-- AnnulnxSpace arV�ultSensor: Model 7 p AnnulerSpace or Vault Sensor �; Model: iping5umplTrenchSensor(s). _ Model: :.0 Model: _ Model. _ Sum Sensors Model: q x Fill Sump Sensor (s) Model: echanicalLine Leak Detector. Model t MechariicalIine LeakDetector. Model: --- Electronic Line Leak Detector Model: ti - tV Electronic Line Leak Detector Model: Ove - ...Model: .. ._ _----.._._: _ 7.0...--- _L._. 1_.. �b—...__._.__._ a andmodel inSe�ction E on P e 2 O+her, S ec • e ui a and model inSection Eon Page 2 �1Other, S ec a ui . Dis enser ID Z - Dispenser ID. _ L" V• P---.. __--=- ---._ _•_ . _ Di en ser Containment Sensors: Model L� Ds enser Containment Sensors) ;Model_ Z+i Shear V alp s . Dis enser Containment Floa s and ChLis is enser Containment Floa s and Ch Dispenser ID: Gi" Dispenser ID: -w - --_ — is enserCoritaiximentSenso s�: Model: G- DispenserCoritairinteriLSensors_ Model: ..--,-------- � Sheer Valve s . ShearValve(s). __ -- is enser Containment Flo a s and Ch ' s` [� is enser Containment Floa s) and Ch s D enser III: -- O Dispenser ID:{� ----- DiseriserContairimantSensors: Model. 2 3 Dss�enserContainment Sensor(sL Model_ p henrValy s . ShearValve(s).-- -- _ . _. ]Dia enser Containment Flo a s and Ch " 's� pDis enser Containment+ Floa s end "If the facility contains more tanks or dispensers, copy this forst. Include information for every tank and dispenser at this fncility. C, Certification -I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacttaeni 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 monitoringegufpment. For any equipment capable of generating such reports, I I=alto attached a copy of_the report; (c eck all that apply): fS System set-ip —I'S—Alam history Mori r' e ciuvcian N erste (Print): Signature: — CertiftcntionNo.: �'�`�� 1License No.: Testing Comp any Name_ TAITENVIRONMENTAL SYSTEMS Phone No.: (?1560-8222 Page I of 3 03A1