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MONITORING SYSTEM CERTIFICATION <br /> For Use*All Jurisdictions Wthin the Slate of California <br /> Authority Cited: Chapter 6.7,Health and Safety Code; Chapter 16, Division 3, 71tle 23, California Code gfRegulations <br /> This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared <br /> for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank <br /> system ownertoperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 <br /> days of test date. <br /> A. General Information <br /> Foci Name SP WEST COAST PRODUCTS. C __._$ _..__ '5450 <br /> LL <br /> Site Addrass: .1617 W FREMONT City_' STOCKTON 1 Zip ,95203 <br /> F a Contact F ers on. ,f�\ Contact Phone N o.: `7 <br /> Data of Te exvsce ,(K <br /> B. Inventory of Equipment Tested/Certified <br /> Ckeck the wEnriate boxes to Wieate gecific a ment hmevctealso * ed: <br /> TankID: Taa1cID: <br /> — - —. <br /> Tarik Gauging Probe; ..... . . Model: TankC3auProba; Model:_I <br /> AnnuterSpsce"-Vex tSensor ; Model: 4 AanuiarSpace orVaultsensor ; Model: <br /> �ngSumpfi'xenchSensor% Model- �_qci — Surn�l�Tranch (s) Model: <br /> Sensor <br /> ilk Sum Sensor q): Model: k ill SumpSensor(e)� __--._ .. Model: 4 <br /> _.. _-- <br /> schanicalLdne Leak Detector. Model: echanicalLine Leak Detector. ', Model- <br /> ectaorric Line Leak Detector Mode.• ctronic Line Leak Detector ` Model <br /> TenkO_verFilUH' IevelSansor Model ankOvexiilUH' level Sensor: Modal <br /> _. __g _ _._'_ _. _lam—_ <br /> Other ec' e e and model in Section E on Pa e 2 er, ec' a .t e and model in Section E on Pa 2 <br /> TankID: ' Tm*M- <br /> In,TankGaugu Prober ..__..._..__... Model r-TankGnuginp�Probe: _.._. . __. htlodeL <br /> ularSpace orVaultSensoz <br /> Model: Model <br /> Amuler-Soucy orVaultSensor : <br /> S_�►fPrenchSensox(i!�: Model: ingSum /T renchSensor(az: Model: <br /> Model: 1-- <br /> F illSumpSensorol:__ Model . <br /> echanicelLineLeakDetector. Model• eehanieal.Line Leak Detector._ i Model: <br /> ectronic Lane Leak Detector Model actronic Line Leak Detector ! Model: <br /> O <br /> TankOverfillMi -level Sensor: Model • ankverfiU/Fiighleveor: <br /> _ ---.. _. ....--- ._.__ .- ._ _..--- .�"1�S,7s 1- 1._ _-_ -- ll.Sens__-_ .. <br /> Other.Sgecify equip.type and model in Section Eon P e2 Other,Spec'SpecA e e and model in Section Eon Page 2 <br /> enser ID: Dis sneer ID: �jg <br /> enserContainmerrtSensors: ! Model_ Mispenser Containment Sensox(s)__ _ Model: � <br /> She--yelve(s). SheesValve�s�___.__ <br /> anserCoatainmentFloa s and a enserContainmentFlo sand Ch ' a <br /> an_sex ID: _ Dis ansae ID: _ <br /> enaerCd n inure Sensors: Model: .__ s enserContainmeritSeasos <br /> Valves . <br /> Dis ens er Containment Flo s and Ch ' : e ens er C omteinment Flo!g!)and Ch ' s <br /> Dispenser ID: ansae ID: <br /> enserContainment amor$: : Model = easerContainmentSensor��_ ModeL• <br /> Shear V aivs�. _ Shear$wed Z- ...... <br /> a ' wiser C ontaimmnt Flo s and Ch ' s ens er C ontainment lo s and ChIts)s <br /> *If the faulty contains more tanks or dispensers,copy this form. Include Wormation for every tank and din anser at this facility. <br /> C. Certification-I Certify that the equipnaext identified in this 8scunAextwss hrspectad/sexaiced in accsriaxce with the mannfasuras' <br /> gnidol m. Attached le this Card6cadon b ixt5sa w&u(04 sauufaetwmn"checklists)necessary to vedfy that thb tahrmatiox b <br /> correct axd a Plot Plan showing the layout of m mitering meat Far any a uipmext capable of generating:uch repents,I hoaeaLo <br /> ateheda capY of the report- hock a!d'that apLaIyJ� .__..._.fSY�.- . so —TWO <br /> _ -._ !M _ _._._.... ___..... <br /> TechaicianNemet;Pnnt): c - .,�, ;_Ssipature <br /> Certification No.: C :C7S-2f�1 i License No.: <br /> _TestingCompanyName: TAITENVIRONMENTALSYSTEMS __Phone No.: (714)560.8222 <br />