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MONITORING SYSTEM CERTIFICATION 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 systems within 30 days of test date. A. General Information Facility Name: Atcc) A-zo ?M -1p --/8�o Bldg.No.: Site Address: 3212 V. C4,k,l as N. ST City: -S/bc,e Rxj G,q, Zip: Facility Contact Person: Contact Contact Phone No.: ($pg ) q c�� Zbgt Make/Model of Monitoring System: of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: —r- / QTyYt�}5 j c /L Tank ID: T Z 197- Si 1�fita} ETI.-Tank Gauging Probe. Model: q�6 320 -/O 9 ❑In-Tank Gauging Probe. Model: 8V.4 390 -/0 4 )� ular Space or Vault Sensor. Model: O:.q c/ 9D - LSD 9 ElAnnular Space or Vault Sensor. Model: :Xago-i112 9 _ Pi ing Sump/Trench Sensor(s). Model: �g U 3,q0- 3 Z3 El Piping Sump/Trench Sensot(s). Model: :e y 3 So -_3Z3 1d Fill Sump Sensor(s). Model: ?-9 y 3dij - ?z'3 ❑Fill Sump Sensor(s). Model: 9`/3Bo 3E 3 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: C?l ❑Electronic Line Leak Detector. Model: G�� ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: % 3 fj I Tank ID: 21'I.-Tank Gauging Probe. Model: 0?e1i 3 fe-/o f ❑In-Tank Gauging Probe. Model. i�ErAnnular Space or Vault Sensor. Model: O`q y.3 ge- Zg'7 ❑Annular Space or Vault Sensor. Mod O PPiping Sump/Trench Sensor(s). Model: 717 q 3Ao — 3 Z3 ❑Piping Sump/Trench Sensor(., odel: Z rill Sump Sensor(.,). Model: 144 396 - 3 Z 3 ❑Fill Sump Sensor(s). Model: ❑��Mechanical Line Leak Detector. Model: ❑Mechanical Detector. Model: 2p Electronic Line Leak Detector. Model: C?F ❑Electro ne Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑T Overfill/High Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). Other(specify equipment type and model in Section E on Page 2). Di user ID: t Dispenser ID:_-3 L� r Dispenser Containment Sensor(s). Model: [Dispenser Containment Sensw(s). Model: _ 6 Shear Valve(s). O Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Cham(s). Dispenser ID: sDispenser ID: 7116 lJ Dispenser Containment Sensor(s). Model: 016ispenser Containment Sensor(s). Model: - k ❑Shear Valve(s). �hear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). D ❑Dispenser Containm odel: E"Dispenser Cont: eait Model: ❑Shear Valve(.,). ❑Shear Valve(s). ❑Dispenser Containment Floats)a�Chain(s). ❑Dispenser Containment Float(.,)and Chain(.,). ;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 equI ent. For any equipme t capable of generating such reports,I have also attached a copy of the report;(check all that apply): 2 System set-up �rm history report Technician Name(print): Pete Garcia Signature: Certification No.: A23970 License.No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.:(925) 551-4777 Testing Company Address: 6747 Sierra Ct., Dublin, Ca Date of Testing/Servicing: Page 1 of 3