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-�` • i ri SystemEquipment *rtification • • For Use By All Jurisdictions Within 7Yte State of California Authority Cited.• Chapter 6:7, Health and Safety Code; Chapter :6, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel 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 system within 30 days of test date. A. General Information Facility Name: Chev 96171 Bldg.No.: Site Address: 6633 Pacific Ave City: Stockton, CA Zip: 95207-3719 Facility Contact Person: Wo,�e_Y Contact Phone No.: (209)477-4294 Make/Model of Monitoring System: li S111 Date of Testing/Servicing: 11/22/08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank M:1'. Tank ID: T, wu i l ❑ jn-Tank Gauging Probe. Model: ❑}n-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Q/ nular Space or Vault Sensor. Model: 94 /? 1C? 61iping Sump\Trench Sensor(s). Model ?cl4�P,U- 352 ■ ping Sump\Trench Sensor(s). Model:7q u 3tE_ Fill Sump Sensor(s). Model'7e14 3W--_Z0 Vill Sump Sensor(s). Model:2gt-l3aQ 2cJ� ❑ Mechanical Line Leak Detector. Model [3Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: A LA 1-f ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section Eon Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: T.� ia7-Ayx Tank ID• ❑,In-Tank Gauging Probe. Model:_ ❑ In-Tank Gauging Probe. Model: C(Annular Space or Vault Sensor. Model: I ❑ Annular Space or Vault Sensor. Model: Vping Sump\Trench Sensor(s). Model: L ' ❑ Piping Sump\Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r�'a�a�'-G'r ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Q/Electronic Line Leak Detector. Model: -1g' ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). D' penser ID• �- D' penser ID• Eispenser Containment Sensor(s). Model: }Dispenser Containment Sensor(s). Model: �!Cf x-13 W-!ZL:52 JZ Shear Valve(s). [Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dkpenser 1% S L6 DW* penser ID -7 ef Spenser Containment Sensor(s). Model: 7443`d6-<l E�ispenser Containment Sensor(s). Model: L3 Shear Valve(s). Er Shear Valve(s). ❑ Dispenser Containment Float(s)ano Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). riespesniser nr ID Di penser ID Containment Sensor(s). Model: C�ispenser Containment Sensor(s). Model:ear Valve(s). Q'Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(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 equipmeu•identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoringeq ' ment. For any equ' ment capable of gene ng such reports,I have also attached a copy of the; (check all that apply): System set-up Alarm ory rep Technician Name(print): Steve Parmenter Signature: Mfg.Cert.9.4-za ja-) ICC#S a i, cif-UT License.No.: 485184 Testing Company Name: Serv.Sta. Sys. Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose CA 95112 Date of Testing/Servicing: 11/22/08 I