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AUG -01-2006 09:06 AM 1209 394475 P.02 M0*1RING SYSTEM CERT ^,ATION o, - se By All Jurisdictions Within the State of Cu.- ornia Authority Cite& Chapter 6 7, Health and Safe* Code; Chapter 16,'Division 3, Fire 23, California Code of Regulations This forth must be used to document testing and servicing of monitoring equipment. A_Marate certification or report mast be Prepare) for pact monitoring sy,stm &2ntr0panel lsy the technician who performs the work. A copy of this form must be provided to the Mai system owner/operator, The owner/operator must submit a copy of this form to the local agency regulating UST systems within 3( days of test date. A. General Inf�mat Facility Name: U06 I Site Address: 6 - Facility Contact Person:_ Make/Model of Monitoring B. Inventory of Equipment Tested/Certified CArck the appropriate boxes to indicate speetBe equipment ins ted/servicej 'task 110- ❑ In -Tank Gauging Probe, Model: ❑ Annular. Space. or Vault Sensor, Model. Q Piing Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical tine Leak Detector. Model: loctronls Lluc Leak Detoctor. Model: ❑ Tank Overfill / High -Level Sensor. Model: Other (specify a ui ment type and model in Section E on P a 2). Tants ID: © In -Tank Gauging probe. Model: ❑ Annular Space or Vault Sensor. :Model: 0 Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s), Model; Mechanical l.,ine Leak Detector, Model: Electronic Line Teak Dsteotor. Model; Tank Overrll / 141gh-t.Qv40 Sezzy.>r. Model; CJther eCl ' ui meat a and mad .l iu :'sectio+z ra wa X' 0 2. , .uispenser ID_ Dispenser Contninmlttlt Sensors}. Mode Shear Valve(s), Dis ver Con a nmell o s an ams . 2ispenser ID. Dispenser _ ContainSens—orent '77Mode-: l Shear'Valve(s), Spenser W. Dispenser Containment Sensor($). Model: Shear Valve($), Dispensor Coptaitrinent Floats) and C.1,4jals}. "rank ID - In -T auging r_07e. Model: Annular Space or Vault Sensor, Model: Piping Sump / Trench Sensor(s), Model: ]Fill Sump Sensor(s), -� Model: :1 Mechanical Line teak Detector, _ Model: Electronic Line Leak Detector. ......... . Model: :1 Tank Overfill / High -Level Sensor, Model: 71 6th &r fewAF . o ............... -- --A -4-1 Ttlnk ID: ❑ In -Tank Gauging Probe, Model: (� Annular Space or Vault Sensor, Model: ------ ❑ Piping Sump / Trench Sensor(s). Model: L� Fill Sump Sensor(s). Model: Mechanical line Leak Detector. Model: Electronic Linc Leak Detector. Model: © Tank Over -fill / High-level Sensor. Mndel: CJ other cif a ul meat a and model in Section E on Luc 2), Dlspcnsur 1D. - Di '5penser D.-Dispenser Containment Sensor($). Model: � Shear Valve{s). —�---�--. ._ penser lD- - Nspenser Containment Sensor(s), Model: Shear VaIve(s). Dispenser Containm Dispenser ID- ent Sensor(s). Model: Shear Valve($), _ zr Tne raeility contains more tatekr or diaperoscrs, copy this .t6rm, Include informati�pn forge po»tatljt a a loat(5) a`ad Chain(s), C. Cettifichhon -1 cert-fy that the equipment identified ill this document 'y tenser nt the TA ility. l;uidcliliCs. Attached to this Cenifzcation. • is infarmat;nn ent �'gs ipected/serviced in a correct and a rilot Alna Aliuwtnl; the layout ofmonimrin (e.s. manufaciurers' checklist ogees$ with rite tASQ ur s attached a copy of the report; (check all that of fnoj g equipment' For any equipment capable ofgeering sole this information is Q System set-ap 13 Alarm history report �olU, I have also Technician Name (print): � Certification No.: Signature: Testing Com an License. No.: 605142 Company Name; West Star Environmental Site Address: , 4ggg yy �enrl-fpr Suite fps / Fresno CA 93722 phone nkat be r; (559)217-9378 Date of fiestirlg/Servicing, gonitoring System Certification Page l of 4 03101