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07/28/2004 15:22 209-57 040 BOYETT PETROLEU PAGE 08/1 MONITORING SYSTEM CE TIFICA► N For Use By All Jurisdictions Within the State of California Aurhority Cited: Chapter 6.7, Health and Safety Code, Chapter 16, ,Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment A 5gggrate certification or repo must be nreeared for each monitoring system cortM9 anel 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 Inforplatiol, Facility Name: 1`K /p"7 .+#7 --- Bldg. No.• Slit Address' COf City: dip' Facility Contact Person: Contact Picone No.:--- Make/Model of Monitoring System: G' S .SZ1 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the anoranriate boxes to indigatc S CUIC a ai meat iaE eCtedtservlccd: Tank ID•orf �r _% 12111n -Tank Causing probe. _ Model:n-Tank Tank ID: Gauging Probe. Model:i -_ anular Sparc or Vault Bonsor. Model: r ` 'b �"�",nnuiar Space or Vault Sensor.. I� FipingSump i french Scnsor(s). Model: Modct:'� Ur Piping Sump I Trench Scnsor(s). Model: .a r~ Qr Meehanicai tine Leak Detector. Model: ❑ Nil Sump Scnsor(s). ❑ Mechanical Line Leak Detector. Model: Model: ❑ Fill Sump Sensor(s). 13 Acchanicel Line Leak Detoctor. Model. Madel: loctronic Linc Lcak Detector. Model; � Mode 'p Electronic Lino Leak Detector. Tank Overfill / ftigh-Lcvcl Sensor. P Model: P,? t1)I� 12rTank Overfill I High -Level Sensor. Model: 2 r :—v3 �. 2). Cl Other (speciry equipment ty a and model in Section Eon PM 2). Cl Other s eci a ui mcnt c and model in Scction b on P c 11) P-T;nkGauging Probe, Model:!,p�dx nnular Spacc or Vault Sensor. ModcL•��r,a .4 .4 ®'piping Sump /'french Sonsor(s). Model: 9XA9 ' . ® ilt Sump Scnsor(s). Model: Qr Meehanicai tine Leak Detector. Model:I-RZA Qa tccUvnic tine Leak Detector. Modal -'T j if �j" fank Ovorfili / High -Level Scnsor. Model: O Other (sr4cit'v equipment type and model in Section G on Page 2). Dispenser ID: .4L/ -,P- Z ❑ Pispenscr Containment Scnsor(s). lear Valve(s). TanklD: ❑ In -Tank Gauging Probe. Model: Q Annular Space oNXault Sensor. Modcl ❑ Piping Sump /'Trcn s*r(s). ct. ❑ Fill Sump Sensor(s). Model: eor. ❑ Mechanical Linc Leak Der- V7ltydst: - or ❑ Electronic Linc Ita Do tor. Model: Cl Tank Overfill / High-Lcvol Sensor. Model: O Other (st)ccify equipment typo and model in Section B on Page 2). Dispenser TID., — ❑ �Dopenscr Containment Sonsor(s). Model: m%5 Car V alve(s). - lid :3 cnscr Containment Float 3 and Chains . Uta nscr t ontainmeni rival s �u:u L:mug . Dispenser ID: Dispenser ID: O ,Disponscr Containment Sensor(s). Model: _ Q Dispenser Containment Srnsor(s). Model: ® Shear Valve(s), I Q Show Valve(s). ® i)istr)cnser Containment fioat(s) and Chain(s). Q Dis ensor Containment Float(s) and Chains . Dispenser IV: I Dispenses' ID: a Dispenser Containment Scnsor(s). Model: I ❑ Dispenser Containment Sctisor(s). Model: O Shear Valve(&), ❑ Shear Valvc(s). UlDisn2mer Containment Vloa!W and Chains . ❑ Dis nscr Containment Floats And Chains . *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and disponscr 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' checkiists) aece3sary to verify that gieinformation is correct and a Plot Plan showing the layout of monitoring equipment For any equip m a e of perntin u sports, t have also attached a copy ofthe �*stem set-up :Il ory ort p�llk Technician Name (print): ,JAS/— _ Signature: Certification No.: f4 a//�"" License. No.: Testing Company Name, ,/�[a►e'.+` Phone No,: ;f, 02j. � .. Site Address. Date of" I'estinoervicing, Page 1 of 3 M unitoring System Certlfieation D3/Q l