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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State oj'California Authority Cited. Chapter 67,Health and Safety Code;Chapter I6. Division 3A-Ifie23,California Code of Regulations This form must be used to document,testing and servicing of monitoring equipment. A separate ccrtificutign,gr YyWrt must he prepared for each c i the work. A copy of this,form must be provided to the tank system ownerloperator. jMLMDjd by the techniciaxi who perfornu The ownerlopenior must&ubmit a copy of this form to the,local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Flldg�No.: '�' '�O_d Site Address: 2'!>-75- Lj_, LL_11" City: Zip- AeLCE337 — FacilityContaciPersom TIL-�L'!9L' Contact Phone No.: Make/Modell of Monitoring System; Date orrestingiservicing! B. Inventory of Equipmentrested/Certified _ft-eck__thea. _ppjr_i_at_t_tonnes toindicatesp- 11cegipment jupteUserAceth Tank ID: Tank ID: 0 In"Fank mojel° 0 In-Tank Gauging Prohc, Model: 0 Annular Space or Vauh Sensor. ModdL 0 Annular Spue or Vault Semor. M4 xfcl: Cj Piping Swnp/Trench Scnsor(s). Model: n Piping Sump/Trench Senior(0. Model: [I Felt Sump Scov-*f'). Mo&l: 0 Fit)Sump SM.Wir(i), Model: 0 Mechanical Fine Leak Detector. Model., [3 Mechanical,Lane Leak Dcm;tor, Model.- 0 Fiectrunic Line Leak Detector, Model: [3 Electronic Line Leak Detector. Modek Tank Overfill i Higb,fxyd Semm Modd: [I Tank Overfill I High-Level Sm%or. Mxk I-. K3thrr rapt city equipment type.acro Mt del in Section a on Page 2). 0 Other(specify equipment type out model in Svaiim Etats Page 2), rank TD, 'rank 10: Q In-Tank Ga-iging,Probe, MWO: 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vauh Scm4r. Modcl; Annular Space or Vault Sensor. Model: *[I piping Saint)/Trench Mc l: C]Piping Sump I Th3ich Sen", &). Model: C1 Filt Sump Sensor(s), Model: 0 Fill Sump Scnw0s). Modes [31%lechanical tang Leak Mawtor. M(Xlcl*. 0 Mechanical line Leak Detector. Model: 0 Uectranic Line Leak Detector. Model: 0 Electronic Line leak Detector. Model: E)*rank Ovcri'ill I 1hghJxvcl Sensor. Model: 0 Tank Overfill I t1igh-Laval Sensor. Model: 0 Chh,,r(spccifv equipment type and mfyJcl in Section E on Pap U [3 other{specify equipment type and model in Section F on Page 21. Dispenser ID; Ir�t1 a Dispenser M-, amspeo%cr Containment Senstv(s)- M� odej: CZ27IS-1 IS Q 0Dispenser Con1aiomaScniorW. Model: 0 Shear Valw(s), 0 Shear Valve(s). 0 DiVcnxcr Containment Floaa(s)and Chain(,;). [3 Dfspcnsa Contamnient Float(s)and Chaiti(t). Dispenser W: Dispenser ID,, [3 1)6penserContainmert Sensor(s). Model. 0 Dispenser Containment Senior(s). ModeL 0 Shear vzjv�<.%). 0 Shear Valve(s). 0 Dispenser Containment float(>)and Maixi(s). C3 Dispenser Containment Float(s)and Chain(&). Dispenser ID: Dispenser ID: Mcidek 0 Dispenser Containment Smor(s), Model: 0 Shear Vafvc(s), 0 Shear Valve(s), 0 Dispmwr Containment FloAt(s)and Chuiru5). El Distpensar Containment Flmt(s)and Chain(s). *If the~facility corwtains more tanks or dispemers,copy this form, Include information for every tank and dispenser at the facility. C. Certification.I tertify that the equipment Identifled In this document was inspectedtserviced In accordance with the numuthaurers' guidelines. Attached to this Certification is information(e g. manufacturers' checid1its)necessary to verity that this Information is correct and a Plot Plan showing the layout of monitariug ulpment. for any equipment capable of generating such reports,I have also attached a copy of the repo",(check all that apply) System set-up 0 Alarm history report Technician Name(print),. Signature: Certification License. 184 Testing Company Naire: Service Station Systems,Inc Phone No,: 408) 971-2445 Testing Company Address: 680 Quinn Ave-San Jose,CA 96112 Date of Testing/Setvicing, -7-20-11 Rev(2/08)