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p <br /> MONIPORING SYSTEM CERTHOATION <br /> For Use ByA11JWU&cftons WidunSwe of Cal, W7da <br /> A uthonty Cited:Chwier 6.7,Health and Safety Code;Chvier 16,Division 3, RX,23, California Code of Regulations <br /> Tins form be used to doctiment testing and servicing of monitoring etluipment.A separate ggacation or rAW Mg be,,MpXgd <br /> for agh mQAMMl nanel by the technician who performsworlL A copy of this form must be provided to the tank <br /> system owner/operator owner/operator st submit a copy of this formto the local agency regulating UST system i 30 <br /> days of test date <br /> A.General 0 atio <br /> Facility Name: Norms 76 ld No: <br /> Site Ad Victor C' : 95240 <br /> Facility ContactPerson: Rob Contact Phone No: 209 7-1795 <br /> Make(Model of o 'o' S : Veeder Root 1 Date of T Servicin : 1/6/ <br /> B. Inventory of EquipmentTested/Cerffied <br /> Tank W Premium Tank ID, Regukr <br /> In-Tank g 2 In-Tank g Probe Model: 734290-307 <br /> Ml Annular Spam or V DF IM Annular Space or Vault Sensor M DF <br /> 121 Piping Sump/T s). : 7 S /T s). Model: <br /> ❑ Fiin S s). 1: ❑ Fill S s). Model: <br /> IM cal L° l: LD 2000 IM Mechanical Line Leak Detector, Model: FX1V <br /> ❑ Electimic Line Leak Detector. M Q Electivnic Line Leak Detector. ModeL <br /> IM Tank Overfill,/ el Sensor. Modek OPW-61SO W Tank Overfill/ . Model: O -61SO <br /> ❑ Other Lsmtx equipment t3w and model in Section E on Page 2). 0 Odier( in Sectim E on P 2). <br /> Tank M. Plus T . <br /> In Tank Gauging Probe Model. 7342 ❑ In Tank Gauging ftbe Model: <br /> Spam or Vault Sensor M F ❑ Annular Space or Vault Sensor Model: <br /> IM Piping S /T s). Model: 7 Q Piping S /Trench Sensor(s). M l: <br /> ❑Fill S s). ❑ Fill S s). Model: <br /> 181 Mechanical Line Leak Detector. M iV 0 Mechanical Lim Leak Detector. Model: <br /> 0 Flectionic Line Leak Detector. M ❑ EI 'c Line Leak Detector. Model: <br /> Tank Overfill/H%h-Level Sensor Model: OPW-61SO ❑ T / l Sensor Model: <br /> ❑ Odw( in Section E 13 ( in E P 2)� . <br /> Dispenser . 1-2 Dispenser ID,. 7-8 <br /> CC Dispimer Containment Sensor(s). s). Model: 406 <br /> 0 Shear V s), y e(s). <br /> IM Dispenser Containment Float(s)and 9M(s). s)and 2ggs). <br /> Dispenser]R 3-4 Dispeaw UD: <br /> 131 Dapenser Containment Sensor(s). Model 406 ❑ Sensor(s). ModeL <br /> 0 Shear Valve(s). ❑ Shear Valve(s). <br /> 0 Dispenser at s)and 9M2 s. Float(s) s). <br /> Dispenser ED:5-6 Dispenser ID, <br /> (8)Dispenser Containment Sensor(s). M s). l: <br /> CM Shear V s). ❑ Shear Valve(s). <br /> IfflDispensers Chain(s). s)and 2M(s). <br /> *If or dispensers, form Include infonnation for evay tank and dispenser at the facility <br /> C. Certification-I identified in this document was inspectefterviced in acro rs' <br /> guidelines. Attached to this Certificatim a information ( ' checklists) necessary to verdy awt this informaiuon is <br /> correct and a Plot Plan showing the layout of monitoring equipment For any equipment: of generatiI have also <br /> attached a copy of the report;(check aU that )z 1XI S -up =h° Vff <br /> ol <br /> Technician Name(p ' ): NMm Griswold Si <br /> cerffication o.: License.No.: S17 I U6 <br /> Testing Company: N Construction Phone N6.: 2 7U4452 <br /> Site Ad r,Lodi CA a of T g: 1/6106 <br /> Page 1 of 3 03MI <br /> Monitoring System <br />