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04-23-'12 10;55 FROM-West Star Envmt Inc. +559-277-0106 T-769 P0002/0006 F-311 Appendix Vi (Copies of Monitoring System Certification form and UST Monitoring Plot Plant available at httDY/www.MLeftards.0a.goV,) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Califomia Authority Cited:Chapter 6.7,Health and Satety Code;Chapter 16,Division 3, Title 23, California Code of Regulations This form must be used to document leafing 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: SUO-4' Bldg.No. C site Address: 2–!70 City:__� �t tip: \� Facility Contact Person: Contact Phone No.: A 01 TA 35 Make/Model of Monitoring System: Date of Testing/Servicing: S. Inventory of Equipment Tested/Certified Check the seemriate boxes to indicate S Cific equI mumt I ected/serviCed: t P 4 [[03Tank In, Tank ID; Tank Gauging Probe. Model: � s '(?�a►n 4- .. � In-Tank Ug ng Probe. Model: nular Space or Vault Sensor. Mogi: Annular Space or Vault Sensor. Motel:-sl*- s,�t U ping Sump/Trench Sensor(s). Model: J Piping Sump i Trench Sensor(s). Model: ll Sump Sensor(s). Model: R 20 �l Fill Sump Sensor(s). Model: u IiL US Mechanical Lurie Leak Detector. Model:�_ �r Menchanical line Leak Detector. Model: Llectronic Line Leak Detector. Model: i Electronic Line Leak Detector. Model: nk Overfill i High-Level Sensor. Model: _ �. Tank Overfill/High-Levet Sensor. Model: "thers Ci a ui ern a and model in SsoWn E oh alp e . 3 Other i e u' ent and model in Section E on P e 2. 11 Tank ID:-Tank Gauging robe, Model:�F YCe.�t• ❑ in-Tani(Gauging Probe. Model: nular Space or Vault Sensor. Model: "alt l Annular Space or Vault Sensor. Model:ping Sump/Trench Sensor(s). Model: i Piping Sump/Trench Sensor(s). Model: ll Sump Sensor(s). Model: vL tee _ ❑ FA Sump$ensor(s). Modelet hamcal Line Leak Detector. Model: R Q __ � Mechanical Line Leak Detector. Model: iI Electronic Line Leak Detector. Model: i Electronic Line beak Detector. Model: ----- t k Tarn Overli/High-Level Sensor. Model• _ i Tank Overfill/High-Level Sensor. Model: O Other spas a u' ant a and model in Section E on P 2. Others ent and modal in Section E on R e 2. Dispenser ID: t S 1. Dispenser ID;,--S i i Dispenser Containment Sensor(s). Model: I Dispenser Containment Sensor(s). Model: Shear Valve(s). Zia Shear vatva(s)_ . Dispenser Containment Floats andha Cins Dispe riser Containment Floc s and Chain(s), Dispenser ID: Dlsperr ID: n Dispenser Containment Serisor(s). Model: 'I Dispenser Contai mann Sensor(s). Model: 1p Shear VMve(s). i Shear Valve(s). it. Dispenser Contalnmeot Floats and Chains. -j Dispariser Containment Fb a and Chain(s). Dispenser ID: DispenserlD 1 u Dispenser Cont6inthent Sensor(s). Model: J Dispenser Containment Sensor(s). Model: .>, Shear Valve(s). 0 Shear Valve(s). 42spenser Containment Floats and Chain(s Dispenser Containment Floats and Chaun(s. 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'cheddlsts)necessary to Verity that this irim matlon is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,i have also attached a copy of the report;(check all than apply. c system Set-up c Alarm/history report Technician Name(print): CA, .t y. 'S�— Signature: c S-� Certlt"ication No.: License.No.: p TeefrV Company Name: t )•G 5 : /LI i V0.r h, &-A Phone No.:(� Testing Company Address:9 � tJ. ��Cnn,�:� \ 1_- Date of Testing/Servicing: Monitoring System Certification Page 1 of 4 12fo7 1 2/21/07