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r Ir in rLUIJI'C RECMTED 0 MONITORING SYSTEM CERTIRATION For Use By All Jurisdictions Within the State of California JAN 2 1 Z003 Authariry Cited: Chapter 6.7. Health and Safety Code: Chapter 16, Division 3, Title Z3. California Code of R� �Mations E ViRONTENT HEALTH This form mast be used to doctttxtetnt testing and servicing of monitoring equipttaent.,& smaat i ed I VP for each rnonitarjngsystem eggntrol vanal by the technician who performs the work. A copy of this form must provided to the tank- system an isystem c,waer/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 formation Hangw Facility Name: k c -El4ft. No.: Site Address: City: k Zip' Facility Contact Person: a r rYn t►� h' �� Contact Phone No.: (� 9) Make/Model. of Monitoring System:�n //e Gtr' " ®`d Date of Testing/Setvicing: __LI_L B. Inventory of Equipment Tested/Certified 5®N : Mtv3 $70Y7 Tank ID: 8 V C4L, -%'`O n VU 41 0 1n -Tank Gauging Probe. Model: 0 Annular Spacc or vault Sensor. Model: I V 2g ®' Piping Sump / Trench Sensor(s). Model:,twn�.St t 2Q14 O Fill Sump Sensor(s). Jai Mechanical Line Leak Detector. Model: Model. ❑ Electronic Linc Leak. Detector. Model: D Tank Overfill / High -Level Scnsor. Model: O Other (specify couioment tytn and model in Section E on Pagc 21. Tank ID: O In -Tank Gauging Probc. Model: Q Annular Space or Vault Sensor. Model: O Piping Sump/ Trench Sensor(s). Model: O Fill Sump Scnsor(s). Model: O Mechanical Linc Leak Detector. Model: ❑ Electronic Line Lcak Detector. Model: O Tank Overfill / High -Level Sensor. Model: O Other (specifyequipment type and model in Section E on Page 2). Dispenser ID: O Dispenser Containment Sensor(s). Model: O Shear Valvc(s). 0 Dispenser Containment Float(s) and Chain(. Dispenser ID. ❑ Dispenser Containment $ensor(s). Modcl: O Shear Valve(s). Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ Shear Valve($). ,If the facility contains more tanks or dispensers, copy this form. Include Tank ID: ❑ In -Tank Gauging Probe. Model: Q Annular Space or Vault Sensor. Model: _ Gi Piping Sump/ Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: D Mechanical Line Leak Detector. Modei: 0 Electronic Linc Leak Detector. Model: Q Tank Overfill / High -Level Sensor. Model: 0 Other (specify cgu� iemennttamed model in Section E on Paee 4 Tank ID: ❑ In -Tank Gauging, Probe. Model: 4 Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Modcl: ❑ Fill Sump Sensot(s). Model: 0 Mechanical Line Leak Detector. Model: U Electronic Linc Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model; O Other (specify equipment t c and model in Section E on Pa,e 2 . re ' Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Q Dispenser Containment Scnsor(s). Model: 0 Shear Valve(s). „ 0 Dispensement Floats) and Chain(s). Dispenser ID - 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). t„; Diseaser Containtncrt Fleatts) aid C'rein(s). _ nformation for every tank and dispenser at the facility. C. Certification -11 certify that the equipment identified in this document was inspectedtserviced in accordance with the manufacturers' guideiines. Attached to this Certification is information (e.g. trwnufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of trtolsltoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all filar apply): 0 System set-up Cl rm history report Technician Nano (print): ® 1/—J.Iy1 I 1 S Signature: Certification No.: 7_ 0 2 O (-(g ( License. No.: 3 I fo D Testing Company Name: S Phone No.:(_2Q�,_) 464-8 33 Site Address: Date of Testing/Servicing; // / 03 Page 1 or 3 Monitoring System Certification ORIGINAL MAILED TO: San Joaquin County Environmental Health Div. Attn: Dennis Catenyag 304 E. Weber St., 3`d Floor Stockton, CA 95202 03/0%