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I. Attachments. <br />Complete the follo, ing checklist: <br />® Yes <br />❑ No* <br />System programming/setupreport(s) attached? (`N/A" means system does not have a printer or otherwise does <br />N/A <br />not produce this type of report.) <br />® Yes <br />❑ No* <br />Alarm history report(s) attached? (`N/A " means system does not have a printer or otherwise does not produce <br />❑ N/A <br />this type of report.) <br />❑ Yes <br />❑ No* <br />Automatic Tank Gauging leak test history/test results report(s) attached? (`N/A " means system does not have a <br />❑x N/A <br />printer or otherwise does not produce this type of report.) <br />❑ Yes <br />I] No <br />Photographs attached? <br />El Yes <br />❑ No* <br />Applicable sections of LG -113 attached? (Available at internet address <br />❑ N/A <br />http://Www.swrcb.ca.gov/cwphome/ust/.) <br />I3x1 Yes <br />❑ No* <br />Manufacturer's specifications/inspection protocol(s) attached? (`N/A " means manufacturer currently has no <br />❑ N/A <br />written procedures) <br />❑ Yes <br />® No <br />Local Implementing Agency or CUPA field inspection report(s) attached? <br />J. Certification = I certify, under penalty of perjury, that foregoing is true and correct to the best of <br />my knowledge. The equipment identified in this document was inspected/serviced as specified above and <br />in accordance with the manufacturer's specifications (if available and as attached). In cases where <br />manufacturer's testing/inspection protocols were not available at the time of service I have conducted the <br />specified testing/inspections based on industry standard practices. I have attached a tag or label to each <br />console, sensor, probe, and device tested/inspected/certified indicating my name, date, nature of service, <br />and company name. <br />Technician: Wayne Stuart Wellock Signature: <br />Licenses: CSLB #518977,A,HAZ,C61/D40,HIC CA Tank Tester #90-1063 - CA Weight & Measures Service Agent #03601 <br />Manufacturer's Certifications: EBW #03770 EMCO/TUTHILL #567551594 INCON #9702037 OMNTEC <br />RED JACKET #7182 RONAN #76020202 UNIVERSAL SENSORS & DEVICES #02-0268 <br />GASBOY/TOKHEIM #24872 VEEDER ROOT (GILBARCO, MARCONI)#567551594 <br />BEADREAU (400 Series) #369 <br />Testing Company: PETRO TECH, 1903 San Miguel Avenue, Santa Rosa, CA 95403 <br />Office: (707) 544 -TECH Fax: (707) 578-7145 E-mail: petrofix@sonic.net <br />