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2 .74.3 = <br />MONITORING SYSTEM CERTIFICATION <br />For Use By All Jurisdictions <br />Within the State of California <br />Authority Cited: Chapter 6.7, Health and Safety Code, <br />Chapter 161 Division 3, Title 23, California Code of Regulations <br />Tnis toren must be used io document testing and servicing of Monitoring eelutorrient. A separate certification or report must be prepared for <br />each monitoring system control panel try the technician who performs the work. A copy of this form mum m, <br />be provided to the tank system <br />ownerloperalor. The awrierloperator must submit a copy of this form to the 1=1 agency regulating UST s w1hin 30 days of test tole. <br />A General Information <br />Facility Name LINITED PACIFIC if $446 <br />bldg. No. <br />Site Address 1403 C(,)LJNI'RY CLUB RLVI) <br />city: STOCKTON zip: 95204 <br />Facility Coniect Person_ <br />Conlactp"WeNo: <br />Makaftodel of Monitoring System, wi-omm),rrism <br />Dille of TestinglServicirigi 51112017 <br />B. Inventory of Equipment TestediCertifiecl <br />Chock the aparoorlate boxes to In !9g!9Tani !=cIed1serviced: <br />Tank ID: 87 Tank Size.- <br />Taink]D: 91 Tank Sire; <br />0 in -Tank Gauging Probe, Model: MAG -I <br />i In -Tank Gauging Piabo. model MAU-1 <br />0 Annular Spa0e or Vault Sensor Model. 302 <br />Annular Space or Vault Sensor. Model- 302 <br />0 Piping Sump i Trench Senswis) M 20911 <br />Piping Sump I Trench Sensor(s). model, 208 <br />0 Fill Sump Sensor(s) Model, <br />❑ Fill Sump Sensor(s). MOO <br />0 Mechanical Line Leak Detector. Model- LD2000 <br />Mechanical Line Leak De r. Model: I.D2000 <br />0 Ekclmnr- Line Leak Detector. Mode[ <br />0 Electronic Line Leak Detector Model: <br />ER Tank Overfill I Ngli-Level Sensor. Model: FLA PP'R <br />0 'rank Overfill I High-Levei Sensor model: FLAPPER <br />0 Other (specify equipment type and model in Section E on Page 2). <br />0 Other {specify equipment type and model in Section Ears Page 2) <br />Tank ID: DIE Tank Sim <br />Tank ID: Tank Size; <br />0 In -Ton Gauging Probe. model. MAO-] <br />0 In -Tank Gauging Probe. Model <br />0 Annular Space or Vault Sensor modec 30.1 <br />0 Anwar Space or Vault Sensor. Model <br />0 Piping Sump I Trench Senscr(s). modcq. 2118 <br />[1 Piping Sump I Trench Sensor(s). Model <br />0 R21 Sump Sensor(s) model. <br />Q Fill Sump Sensor(s). model. <br />14 Meclianical Line Leak Detector modet: I.D20DO <br />Mechanical Line Leak Detector Model. <br />El Electronic Line teak Detector Widel- <br />0 Electronic lane Leak Det of. Model: <br />ED Tank Overfill I fth-Level Sensor Model FLAPPEK <br />0 Tank Overfill t High -Levo Sensor. 1-todel. <br />0 Other (specify equipment type and Modd in Section E on Page 2). <br />❑ Other (specify equipinent type and model in Section E on Page 2) <br />Dispenser ID: 1-2 <br />Dispenser ID: 34 <br />0 Dispenser Containment Scaser(s). jiltoael <br />0 Dispenser Contain Sen s)- Mode� <br />0 SneaT Valve(s). <br />0 Shear Vatve(s) <br />Dispenser Centainment Float(s) and Chain(s). <br />0 Dispenser Containment Posits) and Chain(s). <br />Dispenser ID: 5.6Dispenser <br />ID: 7-8 <br />0 Dispenser Conla-riment Sensoi(s) Model, <br />Dispenser Containment Se s). Model. <br />❑ Shearvalve(s) <br />Shear Valve(s) <br />Dtspenser Containment Floats) and Chain(s). <br />0 Dispenser Containment Float(s) and Chain(s) <br />DispenserID_ <br />Dispenser ID: <br />El Dispenser Containment <br />_ <br />0 Dwriser Containment Sensor(s) Model: <br />Sensor(s). Model: <br />Shear <br />0 ShearVatve(s), <br />0 Shear Valive(s) <br />0 0 Dispenser Ct. man <br />Dispenser Containment noal(s) and Chain(s) <br />0 Dispenser Contairlment Float(s) and Chain(s). <br />*If the facility Contains more Milk$ or dispensers. copy this form Include information for every tank and dispenser at the facility <br />C. Certification - I certify that the equipment identified In this document was Inspescled1serviced In accordance Wth the manufacturers' <br />guidelines. Attached to this Certifimtion is information (e.g. manufacturers" checklists) necessary to verify that this Information is correct <br />and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports. I have also attached a <br />copy of the report: (check all that apply): system got -up <br />19 Alarm history report <br />Technoon Name (print): Ed Steams <br />Signature: <br />Certification No.. A31048 <br />Cense No, <br />Testing Company Name AFF ORDA-TEST <br />Phone No <br />Testing panvAddress 4162 ET GALT, CA 06632k <br />_1?22LIL4-0-0413 <br />Dale of TestingiSenheing, 5/1;17Com <br />Monitoring System Certification <br />Page I of 4 V21107 <br />