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Work Order: 2265668 MONITORING SYSTEM CERTIFICATION For Use By.0Jurisdictions Within the State of California Authority Cited.•Chapter 6.7,Health and Safety Code,•Chapter 16,Drnsion 3, T File 23,California Code of Regulations This form must be used to document testing and servicing of monitoring Ax2o(s oa kfiodall or moon MM ZUKId for each by the technician who perfoinos the work. A copy of this form most be pravidod to the tank system ownal0perstor The ownedoperator mast nbtudt a copy of this form to the local agency regulating UST systems within 30 days of tat date A. Central ftforuntion Facility Name: Bldg.No.: Site Addtraa: 1 City Zip: Fae t)r Contact Person P__ Contact PiAw No. Make/Model of Monitoring System "'��L,e� ' 3 Sb Date of Tw ing/Servicing: B. Inventory of Equipment Tested/Certified Cbxh Me be=a I.divate Tank ID: Tact ID: ❑ Probe. Moder ❑lb-Tank GmM Probe. Model. ❑ 9pax m Vaak S=wr. Madel: p Anoulsr Space a Vaek sensor. Model: ❑Piping /Trench Scows(#). Model ❑Piping SoM/Tmwh Scows(# Model: Goseft Probe. Model. ❑Fill sump s). Modal: ❑Fill S®p S®ws(s} Model: ❑ . Lena Detector. Model: ❑M Line Leak Detector. Model: ❑ Line Last Model: ❑ Line Lack Detector. Model: ❑Task Overfill/Fr40"evel ❑Tank OvaSll/ Sensor. Model: ❑Odff(specify type model in Section E on Page 2}. ❑Otber(specify type and modd in section E on Page 2). Tank M: Tank M. ❑lo-Tmk O hr•Taedc p or V Spas or Voult Seem M ❑Fill Soulp S s). Moack [IFin Sunsp Swaft% Moder ❑Modbonical Use Lek ❑ Line Leak Detector. Model: ❑ Use Leak Model ❑ Line Lek Desecsor. Model. p Tank Ovesfin/ Sesser. Model O Took Overall/FFigh-Level Sensor. Model: ❑Other(Vecdy equipment type and model in Section E on Page 2} Other(specify equipsocat type and mold to section E on Page 2). Diqmuw ID: m ❑ Sm a (s). Modek ❑ Smoot($). Model: ear ❑ShValve(s). ❑Sob= ❑ Fkw(s)and(�sio(s). ❑ Flows)and Cheia(s). Dispeouser ID: W. _ ❑Dispeaser Containment Sensoe(s). Model: ❑ Sema Model: ❑Shear Vafve(s). ❑Sbear Valve(s). ❑ Flo*s)sad Cbia(s). ❑Dispenser Containment Floogs)and Chs*s). Dispenser ID W. ❑Dispenser Cantoisuccut Seow(s). Model: ❑Dbpmw Coutoicincot Sensm(s). Model: ❑Shear Volve(s). ❑Sheer Valves} ❑Dispenser Cantsomwat Floags)and Chois(s). ❑Dispenser Coutnamost Float(s)and Cbvn(s} "If the fatality contains mora tanks or diolmmers,copy this£oto Include infonnation for every conk and dispenser at the facility. C. Certiffication-I certify that the equipsissm fwiestft w in this deenusew wta In accordance with the mea ' Attacked to tbis CArdfication is bf (e g.rim )necasM to vaify that this Information is carred=0 a P1M Plan dworing flue boort of nooseftes equipsocaL For any dat of suet reports,I leave also attached a copy of the report;(chock&U9W )t 0 iyosm wit-Up Technician Name(print): Chris Satz Nicolas S' Certification No.: 633M License.No. Testing N MC. Phone No.:0925) 551-4777 Testing Company 6747 Slerm CL,Dublin,Ca Date of Testing/Servicing: Page 1 of $ Tanknology Inc. 8501 N.MoPac Expressway, Suite 400,Austin,Texas 78759