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_y <br />MONMORING SYSrEM CER"FICUION <br />This form documents the [R] routine testing/inspection ❑ initial start-up ❑ emergency service/repai <br />upgrade/modification of monitoring equipment associated with a ® UST (Underground Storag '' <br />❑ AST (Aboveground Storage Tank) ❑ MST (Marine Storage Tank) system. , <br />�a <br />If more than one monitoring system control panel is installed at the facility, a se crate certification or report sho e va or <br />each monitoring system control panel by the technician who performs the work. A copy of this form mush �pr d the tank <br />system owner/operator and to the local agency having jurisdiction (CUPA/LIA). <br />1; ! <br />A. General Information <br />D. <br />z� <br />ll <br />Date of Test/Service/Inspection 02-04-2003 <br />FACILITY <br />Facility Name: Country Club Food &fuel' <br />1856 Country Club Blvd., Stockton <br />Ay <br />Facility Contact Person: Mr. Phil Elder (209) 462-0652 ` <br />i <br />is <br />LOCAL IMPLEMENTING: AGENCY (LIA or CUP A � I, <br />Agency: San Joaquin County Environmental Health De t 8-3440 <br />Does Agency Require Advance Notice for This Type of Servi "lection? ®YES ❑NO Was Agency Notified? DYES ❑NO <br />Was Inspector Present at Time of Inspection?: ®YES O Na j : Mr. John Jackson <br />r <br />MONITORING SYSTEM <br />Manufacturer/ Make: OMNTEC MFG., I ..,N o f Number: OEL8000 <br />Serial Number: "102098 EL98115 ' s <br />Monitoring System Configuration:. a zs system configured to do? List only active%nabled or in use features/devices) <br />0 printer 0 console an lex console visual alarm(s) ❑ external/remote visual alarm(s) L3fax/modem <br />L3 external/remote audible, ' `' s 'A intains alarm history in memory El product inventory L3vadose (vapor) monitoring <br />0 tank containment liquid r C7 tank containment pressure/vacuum monitoring ❑ dispenser pan liquid monitoring <br />1XI piping/sump/trench contain quid monitoring ❑ piping/sump/trench containment pressure/vacuum monitoring ❑ SIR <br />❑ continuous in -tank 1 k on (CSLD, SCALD, etc.) ❑ periodic in -tank leak detection (ATG) ❑ overfill prevention <br />❑ pressurized productw leak detection (LLD) 0 positive pump ❑ overfill prevention <br />hydrostatic rese ,' m' : ring ❑ vacuum monitoring ❑ pressure monitoring ❑ ground water monitoring <br />Ll OTHER <br />