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°86-28-'10 14:11 FROM-West Star Envmt Inc. +559-277-0106 T-708 P0002/0007 F-325 ` M®N1 RING SYSTEM CERTIP&ATIUN For Use By A11 Jurisdictions Within the State of Ca ornia Authority Cite& Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, Tit e 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A sear to certific tion or report const be Prepared for each monitoring,4ystem 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 systems within 30 days of test date. A. General Informatiiou� Bldg.No.:- i1 Facility Name: Site Address: City. C Zip: C Facility Contact Person: Contact Pho No.: Make/Model of Monitoring System:_,,_ r�� C� _-_ Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/soreieed: Tank iii}- ank l� In-Tank Gau g Probe. M el: -Toa Gauging Probe. Model: Annular.Space or Vault Sensor. Model. — IF nnular Space or Vault Sensor. Model: iping Sump/Trench Sensor(s). Madel: 1 ping Sump/Trench Sensor(s). Model; Fill Sump Sensor(s). Model: _ ll Sump Sensor($). Mechanical Line Leak Detector. Model: �� echanical Live Leal:Detector. Model: leetronic Line Leak Detector. Model: ectronic Line Leak Detector. Model: ank Overfill/I-Ii Tank Model- overfill/High-Level Sensor.Model: gli-Level Sensor.Model: Other( ei ui Ynent a and model in Sectio on P e 2. Other s ec a ui ment and model in Sectio on Pa Tank ID: Tank ID: In-Tank Gauging 'be. Model: In-Tank Gauging robe. Model: Q Annular Space or Vault Sensor. Model: —Q YN ular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: iping Sump/Trench Sensor(s). Model: -L Fill Sump Sensor($). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: echanical Line Leak Detector. Model.• lectronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: _ auk Overfill/High-Level Sensor.Model: ank Overfill 1 High-Level Sensor.Model: Other(s eci ai ment type and model in Section n Pae 2. Other'($ cify a ui sent ty a and model in Secc_t on a 2). Dispenser ID- Dispenser ID.- Dispenser Containment ensor(s).Model: Dispenser Containm rat Sensor($).Model: Shear Valve(s). hear Valve(s). is enser Containment Floatisl and a s . Dis sneer containment oats sins . Dispenser ID- __ Dispenser ID. Dispenser Containment�ensor(s).Model;_ "Ck Dispenser Containme t Sensor(s).Model:- —d:O$ Shear Valve(s). car Valve(s). is Cou s s. Di ser cont ainmen oa s an ain s isperaser isp er er Dispenser Containment Sensor(s).Model: .2, Dispenser Containment. 'o s).Model: Dispenser ID- hear Valve(s). Shear Valve($). Dispenser Containment Float(s)and Chain(s). ❑DIspenser Containment Float(s)and Cbain(s). _ •If the facility contains more tanks or dispensers,copy this form.Include information for every tank:and dispenser at the Tacility. C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the man9facW0ers' guidelines.Attached to this Certification is information(e.g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment.Fon'any eFAlarm ent capable of generating such.reports,I have also attached a copy of the report;(check all that apply): System set-up history report Technician Name(print): Nick Adamitz Signature: O Certification No.: 0 License,No.:605142 Testing Company Name: West Star Environmental Phone Number: (558)277-937$ Site Address: 4658 W.Jennifer Suit® 101 / Fresno CA 93722 Date of Testing/Servicing: � Monitoring System stem Certification peg Qo_sd�