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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 prgpared 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 n Facility Name: AtC.a A—tyl Bldg.No.: Site Address: S2/2_ N. C.4L-o Si— City: S72�G,e-R.),j C=A Zip: Facility Contact Person: A)_ Contact Phone No.: (1-09 9 5(� 0, Make/Model of Monitoring System: �-�S— 3 Sp Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: T j $} 0.t,�i�A, Tank ID: T 2- Lr,1/m-Tank Crauging Probe. Model: RV 6 39 O -/Q 9 [IIn-TankGauging Probe. Model: a c4i 390-/C 9 LSI ular Space or Vault Sensor. Model: 044 t/191)- j-1 t)9 El Annular Space or Vault Sensor. Model: ��9't� 390-49 Piping Sump/Trench Sensor(s). Model: 11V1,40- 3 Z7 C3 Piping Sump/Trench Sensor(s). Model: .O y 3 Ifo-3 2 3 rll Sump Sensor(s). Model: 9 y SAID - 32 3 ❑Fill Sump Sensor(s). Model: 1-/390-3Z3 hanical Line Leak Detector. Model: ❑Mechanical line Leak Detector. Model: Electronic Line Leak Detector. Model: C?% ❑Electronic Line Leak Detector. Model: G i ❑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 9 i Tank M �In-Tank Gauging Probe. Model: 0114 3 QD-lo f' ❑In-Ta;Spacc Probe. Model: �Annular Space or Vault Sensor. Model: OQy 3 gp- /D`I ❑AnnulVauh Sensor. Mo {�C�I PPiping Sump/Trench Sensor(s). Model: -7ej y 3Pa — 3 27 ❑Pipingnch Sensors odel:ICI''ill Sump Sensor(s). Model: `i4y 39'a - 2 3 ❑Fill Su (s). Model: Mechanical Line Leak Detector. Model: ❑MahaDetector. Model:ICIElectronic Line Leak Detector. Model: C?% ❑Electroeak Detector. Model: ❑Tank Overfill/High-Levet 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). Dispenser ID: I Dispenser ID: 3 /`� R Dispenser Containment Sensorts). Model: (Dispenser Containm�t Sensor(s). Model. Shear Valve(s). �Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: s�(� Dispenser ID: y�8 1_I DispenserContainment Sensor(s). Model: Containment Sensor(s). Model: D Shear Valve(s). Shear Valve(s). ❑Dispenser Containment Float(s)and Chars). ❑Dispenser Containment Float(s)and Chain(s). t D ❑Dilaivc(s er Contamm odel: ❑Dispenser ContainmentModel: ❑Sh ). Shear Valve(s). ❑Dier Containment Floats)and Chain(s). ❑Dispenser Containment:Fl7ot(s) dChars). '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): 8 Sy tem set-up III 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: 7 Z,—p� Page 1 of 3