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YA'l1'1'VITO%`bING SYSTEM C t RTIC.' ICATION For Use By 411 Jurisdictions ffqthirr the Stale of California Authority Cited.— Chapter, 6.7, flealtlr and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monlioring equipment. -If rnaw thatr aria rrtanilar ap e�i�c�oi et pnnei Is i siallad'ati tho faoiftty it -A sgpgra e ce ' q�ttioa_or t�t2ort mus�be prepared for each monitoring systent_coutrnl panel by the technician who P066tnts 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 bays of test date. I steuatier rs 13�irtted-en th�HaelFef pago A. Genet -,,fl Tnfoi-mtation Facility Name: _� /rtaC Bldg. No.: Site Address: � S �,,.1 _ City: SCA`oYl Gip: �j53w - Facility Contact Person: Contact Plrone No.: _ Make/Model of Monitoring System: -r y,- %0 Date of Testing/Servicing y �� R. hi ventocy of Egltiprnent Tested/Cea•tified Ch 1 ft.. ro rrl rtc boxes to indfente s ecitic a ui merit ins ected/serviceds' *If the facility contains more tanks or dispensers, copy this form, Include information for every tank and dispenser 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' checklists) necessary to verify that this information is correct and a Sito-Plot Ilan showing the layout of morritoring egulpment. nor any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): [❑ System set -tip [] Alarni tri tory report Technician Name (print): Anthony Lelvas Cgr_lificatiou No,: b43182 License. No.; 8220961 " Testing Company Name: Donlee Pump Company Plione No.: 209 537-9396 Testing Company Address: 2825 Railroad Ave Ceres, CA. 95307 Date of Testing/Servicing: - UN -036 - 116 x ww.rrnidoes.o g Rev. 01/11/08 Tonic TD: Tank ID: ❑ ►n -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annntar Space or Vault Sensor. Model: ❑ Annular Space or Vanit Sensor. Model: E]Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump /Trench Sensor(s). Model: ❑ Pill Sump Sensor(s). Model: ❑ Dill Sump Scnsor(s). Model: Mechanical Lite Leak Detector. Model: La ❑ Mechanical Lire Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line leak Detector. Model: F] Tank Overfill / Iiigh-Level Sensor. Model: 0 Tank Overfill / high -Levet Sensor. Model: ® Other (specify equipment type and model in Section E on Page 2). ❑ Other (specif} equipment type and model in Section B on Page 2). Tanic ID: Tank ID: ❑ In -Tank Gauging Probe. Model: El fn -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: n Annular Space or Vault Sensor, Model: El Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump 1 Trench Sensor(s). Model; Pill Sump Sensor(s). Model: © Bill Sunrp Sensor(s). Model: Q Mechanical Line Leak Detector. Model: ® Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Tank Overfill i High -Level Sensor. Model: 0 Tank Overfill / High -Level Sensor, Modbl: ❑ other (specify equipment type and model in Section Hen Page 2). ❑ Other (specify equipment type and mode( in Section E on Page 2). Dispenser ID:' Dispenser M- ❑ Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Q Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: [i Dispenser Containinent Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s), ❑ Dispenser Containment Float(s) rind Chain(s). ' ❑ Dispenser Containment floats) and Chaln(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: El Shear Valve(s). ❑ Slienr Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chnin(s). *If the facility contains more tanks or dispensers, copy this form, Include information for every tank and dispenser 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' checklists) necessary to verify that this information is correct and a Sito-Plot Ilan showing the layout of morritoring egulpment. nor any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): [❑ System set -tip [] Alarni tri tory report Technician Name (print): Anthony Lelvas Cgr_lificatiou No,: b43182 License. No.; 8220961 " Testing Company Name: Donlee Pump Company Plione No.: 209 537-9396 Testing Company Address: 2825 Railroad Ave Ceres, CA. 95307 Date of Testing/Servicing: - UN -036 - 116 x ww.rrnidoes.o g Rev. 01/11/08