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Home My WebLink About2011 RESULTSMONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State ofCalifornia Authority Cited.• Chapter 6.7, Healih and Safety Code; Chapter 16, Division 3, Title.23, California Code ofRegulations 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 ofthis form must be provided to the tank system owner /operator. The owner /operator must submits copy ofthis form to the locttl'agency.regulating UST systems within 30 days oftest date. A. General Information Facility Name: A -ONE FOOD STORE Bldg. No.: Site Address: 1200 H STREET City: BAKERSFIELD Zip: 93301 Facility Contact Person: BOBBY Contact Phone No.: X661) 324 -4138 Make/Model of Monitoring System: TLS -350 Date ofTesting/Servicing: 4/1812011 B. Invelntory of Equipment Tested/Certified Check the a ro riatc boxes to indicate specific equipment inspected/serviced: Tank ID: UNL87.(SPLIT) Tank ED: PREM91 (SPLIT) E In -TankGauging Probe. Model: MAG E In -Tank Gauging Probe. Model: MAG E Annular Space or Vault Sensor. Model: 420(SPUT) E Annular Space orVault Sensor. Model: 420 (SPLID S. Piping Sump. /Trench Sensor(s). Model: 206 S Piping Sump / Trench, Sensor(s). Model: 208 Fill• Sump :Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Linc Leak Detector. Model: RED JACKET N. Mechanical Line Leak Detector. Model: RED JACKET Electronic Line Lcak.Dotector. Model: Elecroni6 Line Leak Detector. Model: TankOverfill / High - LevelSensor. Model,: Tank Overfill/ High - Level. Sensor. Model: Other (specify equipment type and model in Section E on Paget).. Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ED: 01n- Tank0auging Probe: Model- ln- Tanh.Gauging Probe. Model: Annular. Spay orVault Sensor. Model: Annular Space or Vault Sensor. Model: 0 Piping Surnp / Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: Fill Sump Senor). Model: Fill Sump.Sensor(s). Model: Mechanical Line. Leak Detector. Model: Mechanical. Line Leak Detector. Model: Electronic. Line. Leak Detector.. Model:- Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Tank Overfill / High- LevclSensor. Model: Other (specify equipment typeand model in Section ,E on Pagc 2). Other (specify equipment type and model in Section Eon;Pag'e 2). Dispenser ID:. 112 Dispenser ID: 314 Dispenser Containment Sensor(s)_ Model: 208` E Dispenser Containment Sensor(s). Model`. 208 Shear Valve(s). S Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Cbain(s). Dispenser ID: 516 Dispenser ID: 718 S Dispenser,Coniainment Sensor(s). Model:, 406 E Dispenser Containment Sensor(s). Model-.406 ShearValve(s). Shear Valve(s). iiispeiiscrContai 6 nt Flpat(s). and Chains) _ I Dispenser Containment:Float(s)'and Cbain(s). Dispenser ID: Dispenser ID: Dispenser.Contairmerd Sensor(s). Model: Dispenser Containment Sensor(s). Model: El,-Shear Valve(s). Dispense,fotrteiamenkF7oa*) andiChai0 ): Dispenser.Containment Float(s) andChain(s). If•the facility contains more;taiiks or , spepsers;•copy this form. include information for every tank and dispenser at the facility. w.- C Certifieation - I- certify that: the, equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines: Attached to this Certification is information .(e.g. manufacturers' checklists) necessary to verify that this information is j. correct and a Plot Plan showing the layout of monitoring uipment , For any equi mentcapable of generating such` reports, I have also attacheda copy of-the report; (check alt that apply)- Z.Sy§tem set -up larm history report TechnicianName (print): RYAN._MASON' Signature: Certification No.: A273671 8028371 -UT License. No. 6119# 809850 Testing. Company Name: RICH ENVIRONMENTAL . Pho o.: (661). 392 -8687 Testing: Company Address:; 5643. BROOKS CT. BAKERSFIELD,: CA -93308 Date of Testing/Seryicing: 411812011 Page 1 of 5 UN -036 -1/4 www.unidomorg Rev. 01/17/08 Monitoring System Certification D. Results of Testing/Ser4cing Software Version Installed: 419.05 rmmnlete the•fnllnwino checklist- too/ I k Yes p No* Is the audible alarm operational? Yes NO Is the visual alarm: operational? Yes No* Were all sensors' visually inspected, functionally tested, and confirmed operational? Yes No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their. proper operation? Yes No* If" alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem) N/A operational? Yes 0 No* For pressurized piping systems, does the turbine auiomatically shut down if the piping secondary containment I N/A monitoring system' detects a leak, fails to operate, or is electrically disconnected? ifyes: which sensors initiate positive shut -down? .,(Check all that apply) ® Sump/Trench Sensors; ®Dispenser Containment Sensors. Did,you.confum positive shutdown due toleaks end sensor. failure/disconneetion? ® Yes;. E] Nos, Yes No * For ,tank systems that utilize the :monitoring system as the primary. 'tank 'oyerfill warning device (i.e., no N/A mechanical overfill prevention valve is installed), is the overfill Warning alarm visible -and aud'ibl'e at the tank fill point(s) and operating properly? If so, atwhat percent oftank capacity does the alarm..trigger? % Yes* No Was any monitoring equipment'replaced? If yes, identify specific sensors, probes, or other equipment.replaced' and list the manufacturer name and model for all replacement parts in Section E, below. E] Yes' No Was liquid found inside any secondary containment systems designed as dry systems? (Check all -that apply) Product; Water. Ifyes, describe causes in Section E, below. Yes No* Was monitoring system set -up reviewed to ensure proper settings? Attach set up: reports, ifapplicable Yes No* Is all monitoring :equiptnent.operational per manufacturer's specifications? isk• In Section. K belo,W, describe,how' and when these deficiencies wert.or will be corrected. Comment`s: "v F II h Page 2 of S UN -036 — 214 www.unidoes.org Rev. 01/17/08 Monitoring System Gertifieation 4o4fio . 7 F. In -Tank Gauging /`SlREquipment: ® Check this box iftank gauging is used onlyfor inventory control. Check this box ifno tank gaugingor SIR equipment is installed. This section must :be. completed if in -tank gauging equipment is used to perform leak detection monitoring. Complete the following,checklist: Yes No* Has all input wiring been.inspected.for proper entry andtermination,: including testing for ground faults? Yes No* Were:all tank gauging'probes visually inspected for damage and residue buildup? Yes No$ Was accuracy ofsystem product level readings tested? Yes No* Was accuracy ofsystem water'level readings tested? Yes No* Were'.all probes reinstalled properly? Yes No* Were.ali items on the equipment manufacturer's maintenance checklist completed? In Section H, below, describe how and. when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): Check this box. ifLLDs are not installed. Yes El 'No* For equipment start-up. or annual: equipment certification, was a leak simulated to verify 'LLD performance? N /A (Check all that apply) Simulated leak rate: ® 3 g.p.h.; 0.1 g.p.h ; [10.2 g.p.h. Yes , 'No* ' Were all LLDs confirmed operational and accurate within regulatory requirements? Yes No* Was the testing apparatus properly calibrated? r Yes No* For mechanical.LLDs; does the,LLD restrict product flow if it detects a leak? N/A Yes No* For, electronic LLDs, does the turbine automaticallyshut.off ifthe LLD detects a leak? N/A Yes No*, for electronic LLDs, does the> turbine automatically shut off if any portion of the monitoring. system is disabled'; 19 N/A or disconnected? Yes No* Forelectronic LLDs, does the turbine automatically shut off'if any portion ofthe monitoring system malfunctions N/A or fails a test? Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected? j L® N/A, Yes No* Were all items onthe equipmentmanufacturer 's;maintenance checklist completed. In Section H, below, describe how' and when thesedeficiencies.were or will be corrected. H,. om>tents• CY t1iN " t Yic («: I UN -036 — 3/4 Page -3 of S www.unidocs.org Rev. 01 /17 /08. MOG1t0 S. stem;eski ic ti{n' . ASST :ring' P1':: N4 'r w r a* r y. 1 r. ..}1. 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T.. -r. .* • e .. .. r 'r . :a. a. t r. T e r ' . '. r:!, w ":. 'r' :Y ilr r + ni: .r w: .r -s:. r 'r r 'i r:w i'l:r r. r .r r'r` . "w.. r : _ r 1.. w. r r r.r r r:.'_' r. r r a •.t r r ip -_• 4 •. :.M t, r pe .'Ir 7. tY .. d. - fi..: 'T' 1 j: _ Tt:.a .r r ,r ra. ::1 r _ f 'VERS10N.419.05SOFTWARE0346419 - 100 -F CREATED — 00.02.25.12.40 S— MODULE# 3301;61-001 —a SYSTEM FEATURES: PERIODIC IN -TANK TESTS ANNUAL I N -TANK TE13TS:; SYSTEM —SETUP — — _ — APR 18, 2011 11:27 AM SYSTEM UNITS U.S. SYSTEM LANGUAGE ENGLISH. SYSTEM DATE /TIME FORMAT MON DD YYYY HH:MM:SS xM ACNE STORE 1',200 H ' ST BAKERSFI'EI:D °.CA 93301 661 -324 -4138 SHIFT,' TIME 1 5::45 AM SH,I.FT'TIME,'2 DISABLED SHIFT , TIME 3 DISABLED SHIFT TIME 4 : DISABLED a TANK PER TST NEEDED WRN DISABLED TANK ANN TST NEEDED WRN DISABLED LINE PER TST NEEDED WRN DISABLED LINE ANN TST NEEDED WRN DISABLED PRINT TC VOLUMESENABLED TEMP COMPENSATION VALUE (DEG :F ): 60.0 STI'.CK' HE•1GHT OFFSET DISABLED H- ,P.WTOGOL DATA FORMAT DA. LIGHT 'SAVI NGi' TIME rST DATE- r. R! T 2 :;PREMIUM PRODUCT CODE 2 THERMAL COEFF :.000700 TANK DIAMETER 128.00 TANK PROFILE 1 PT FULL VOL 7026 FLOAT .S I:ZE : , 4.0 ,;1 N,... ;8496 WATER:WARNING 2.0 H:1GH °WATER LIMIT: 3.0 MAX OR LABEL VOLT 7026 OVERFILL LIMIT 90% MANIFOLDED TANKS 6323 HIGH PRODUCT 95% ANNUAL TEST FAIL 6674 DELIVERY LIMIT : 9% IIICII 700 LOW PRODUCT 500 LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 50 TANK TILT 0.00 MANIFOLDED TANKS NORMALLY CLOSED TO: NONE LIQUID SENSOR SETUP L 1 :DISP ;1 -2TRI- STATE` (SINGLE FLOAT) CATEGORY DISPENSER PAN L ,2:DISP 3 -4 TRI -STATE (SINGLE FLOAT) CATEGORY ; DISPENSER PAN L 3`:87 STP TRI- STATE.(SINGL£ FLOAT) CATEGORY : STP SUMP L 4:92 STP TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP*, L 5:ANNULAR NORMALLY CLOSED CATEGORY : ANNULAR.SPACE LEAK 'MI-N PERIODIC.:. 90/0 K ...._,. _.. ---- -- 700 R 2:92 MIN ANNUAL.' `% TYPE. LEAK 7`00 STANDARD PERIODIC TEST TYPE NORMALLY CLOSED STANDARD ANNUAL TEST FAIL EXTERNAL INPUT SETUPALARM ;DISABLEDIIICII NONE P.E,R I;ODIC _TEST . FA I L awe I ;. ` ALARM :DISABLED GROSS TEST FAIL, ALARM,DISABLED I 'ANN TEST' AVERAGI,NG':: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF TNK TST SIPHON BRIM :OFF OUTPUT RELAY SETUP .' DELIVERY DELAY : 15 MIN R 1:87 TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOR ALMS ALARM HISTORY REPOR co SYSTEM ALARM - - - -- PAPER OUT MAR 25. 2011 . 7:15 PM PRINTER ERROR MAR 25. 2011 7:15 PM BATTERY IS OFF JAN 1, 1996 8:.00 AM x x x x x END x x x* x ALARM HISTORY REPORT IN -TANK ALARM - T 1 :,REG 1JNL OVERFILL ALARM SEP 2, =2010 3:14 PM OCT -24, 2008 9:19 AM SEP 30, 2008 1:35 PM LOW PRODUCT ALARM MAR 21, 2011 1,0:14 AM FEB 22. 2011 12:14 PM FEB 6. 2011 11:15 AM HIGH PRODUCT ALARM DEC 27, 2006 1:13 PM DEC 15, 2006 2:16 PM DEC 8. 2006 4:25 PM INVALID FUEL LEVEL MAR 21, 20.11 10:34 AM FEB 22. 2011 12:43 PM FEB 6, 2011 11:49 AM PROBE OUT MAR 21, 2005 11:06 AM MAR 1,0, 2005 11:43:AM SEP 4, 2003 3:16 :PM DELIVERY NEEDED MAR 20, 2011 9:53 AM FEE .21., 2014 9:20 AMFEH13'', 2011 6:14 PM xxxxx END xxxxx ALL:FUEL ALARM R 2:92 TYPE. STANDARDLEAKTESTMETHODNORMALLYCLOSED r TEST ON" DATE,.: ` ALL..TANK APR 25. 2001.; LI9UID SENSOR: ALMS START TIME ;: 2:30 AM ALL:FUEL ALARM I'TEST-!RATE :014201 GAL/HR w DURATION 2 I )HOURS LEAK TEST REPORT ,FORMAT ENHANCED ALARM HISTORY REPOR co SYSTEM ALARM - - - -- PAPER OUT MAR 25. 2011 . 7:15 PM PRINTER ERROR MAR 25. 2011 7:15 PM BATTERY IS OFF JAN 1, 1996 8:.00 AM x x x x x END x x x* x ALARM HISTORY REPORT IN -TANK ALARM - T 1 :,REG 1JNL OVERFILL ALARM SEP 2, =2010 3:14 PM OCT -24, 2008 9:19 AM SEP 30, 2008 1:35 PM LOW PRODUCT ALARM MAR 21, 2011 1,0:14 AM FEB 22. 2011 12:14 PM FEB 6. 2011 11:15 AM HIGH PRODUCT ALARM DEC 27, 2006 1:13 PM DEC 15, 2006 2:16 PM DEC 8. 2006 4:25 PM INVALID FUEL LEVEL MAR 21, 20.11 10:34 AM FEB 22. 2011 12:43 PM FEB 6, 2011 11:49 AM PROBE OUT MAR 21, 2005 11:06 AM MAR 1,0, 2005 11:43:AM SEP 4, 2003 3:16 :PM DELIVERY NEEDED MAR 20, 2011 9:53 AM FEE .21., 2014 9:20 AMFEH13'', 2011 6:14 PM xxxxx END xxxxx ALARM HISTORY REPORT 1NLTANK ALARM. - -:_ -- T 2:PREMIUM LOW PRODUCT ALARM JUN 5. 2007 10.:.57 PM FEB 20, 2007 2:01 PM FEB 2,'2007-9:31 AM PROBE OUT FEB 26, 2011 6:29 PM MAR 21, 2005 11:06 AM MAR 10, 2005.11:22 AM DELIVERY 14EEDED FEB 22. 2011 7:46 AM FEB 13. 2011 5:41 :PM SEP 17, 2010 10:05 AM x ,* END X ALARM HISTORY REPORT SENSOR ALARM - - - -- L 1:D1SP. 1 -2 DI;SPENSER , PAN,,,. SENSOR OUT ALARM- ; APR'1B, 2011 . 1,0.;36 AM FUEL ALARM APR 18, 2011 10 :34 AM SENSOR OUT ALARM APR 26, 2010 10::34 AM x x** x END x x* x ALARM HISTORY REPORT SENSOR ALARM - - - -- L 2 :DISP 3 -4 DISPENSER PAN SENSOR OUT ALARM APR 18. 2011 IO "36 AM FUEL.ALARM APR 18, 2011 10:35 AM SENSOR OUT ALARM APR 26, 2010 10134 AM X,XXXE ND: xxxx* ALARM. HISTORY REPORT SENSOR ALARM - - - -- L 3:87 STP STP SLUMP SENSOR OUT ALARM APR 18, 20.1 -1 10:36 AM FUEL.ALARM APR 18., 20 -11 10:32 AM FUEL ALARM MAR 20. 2011 7:00 PM x*** END K* )( )( x END XXxxx ALARM HISTORY REPORT SENSOR 'ALARM - - - -- L 5:ANNUL.ARANNULARSPACE FUEL ALARM APR 18; 2011 10.36 AM FUEL ALARM OR 1.8..._2011 10 :32 AM FUEL ALARM APR 26, 2010 10:34 AM x x x ** END * R x x x ALARM HISTORY REPORT SENSOR ALARM - - - L 4:92 STP STP SUMP SENSOR.OUT ALARM, APR 1 -8, 2011> 10.36 AM FUEL ALARM APR 18, 2011 10:31 AM FUEL ALARM MAR 23, 2011 3:14.PM END XXxxx ALARM HISTORY REPORT SENSOR 'ALARM - - - -- L 5:ANNUL.ARANNULARSPACE FUEL ALARM APR 18; 2011 10.36 AM FUEL ALARM OR 1.8..._2011 10 :32 AM FUEL ALARM APR 26, 2010 10:34 AM x x x ** END * R x x x AICH, ENVIROAMENTAL 5643 BROOKS. CT.. BAKERSFIELD, CA. 93308 OFFICE (661)392 -8687 FAX (661)392 -0621 PRODUCT LINE LEAK DETECTOR TEST WORK SHEET W /0 #: FACILITY NAME: A -ONE FOOD STORE FACILITY ADDRESS: 1200 H STREET, BAKERSFIELD, CA PRODUCT LINE TYPE: PRESSURE L 0$00 f- PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS BELOW P.S.I. OR SERIAL NUMBER 3 G.P.H. FAIL 87 L/D TYPE: RED:JACKET . YES: 9 PASS SERIAL:# 7921 91 L/D TYPE: RED JACKET YES 8 PASS SERIAL # 7915 LID TYPE: YES PASS SERIAL '# NO FAIL L/D TYPE: YES PASS SERIAL # NO FAIT, I CERTIFY THE ABOVE TESTS WERE CONDUCTED'ON THIS DATE ACCORDING TO RED JACKET PUMPS FIELD TEST APPARATUS TESTING PROCEDURE AND. LIMITATIONS. THE MECHANICAL LEAK DETECTOR TEST PASS / FAIL IS DETERMINED BY USING A LOW FLOW THRESHOLD TRIP RATE OF 3 GALLONSTER HOURIORLESS AT 10 P.S.I. I ACKNOWLEDGE THAT ALL DATA COLLECTED 'IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. TECHNICIAN - RYANMASON SIGNATURE: DATE: 4/18/11 0 s SWRCB, January 2006 Spill Bucket Testing Report Form Thisform is intendedfor use by contractors performing annual testing ofUSTspill containment structures. The completedform and printoutsfrom tests (fapplicable), should beprovided to thefacility owner /operatorfor submittal to the local:' regulatory agency. 1. FACILITY INFORMATION Facility Name: A-ONE FOOD STORE Date of Testing: 4118/11 FacilityAddress: 1200 H STREET, BAKERSFIELD, CA Facility Contact: BOBBY Phone: 661- 324 -4138 Date Local Agency Was Notified ofTesting: Name of LocalAgency Inspector (fpresent during testing): ESTHER DURAN 2. TESTING,CONTRAC".TOR INFORMATION Company Name: RICH ENVIRONMENTAL Technician Conducting Test: RYAN MASON Credentials ": CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Specify) License Number(s): 8029371 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic Vacuum Other Test Equipment Used: VISUAL Equipment Resolution: 0 Identify,Spill Bucket (By Tank Number, Stored Product etc. ) 1 87 FILL 2 91 FILL 3 4 Bucket Installation Type: X Direct Bury GContained in Sum X Direct Bury 0. Contained in Sop Direct Bury Contained in Sump C,'.Direct Bury Contained in Sum Bucket Diameter: 121N 121N Bucket Depth: 161N 161N Waittime between applying vacuum/water and start oftest: 30 MIN 30 MIN 30 MIN Test Start Time (Ti)-. 9:OOA 9:OOA Initial Reading,(Rj): IOIN l0IN Test End Time (TP): 10:OOA 10:OOA Final Reading.(RF).: IOIN JOIN felt Duration' (TP -_Ti): 1 -HOUR 1 -HOUR 1 -HOUR Ctiaiige `th eadmg'(R'F ki): 0 0 Pass/Fail Threshold'or'_ Criteria: 0.00 0.00 0.00 Coinments — (include information-on repairs made prior to testing, and recommendedfollow -upforfailed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE. FOR CONDUCTING THIS TESTING I hereby certify that all:the information contained in this report is true, accurate, and infull compliance with, legal requirements. Technician's Signature: State laws and regulations may be-more stringent. r Date: 4/18/1'1 testing to be performed by a qualified contractor. However, local requirements MONITOR CERT. FAILURE REPORT SITE NAME: A,ONE FOOD STORE DATE; 4/18/11 THE FOLLOWING COMPONENTS WERE REPLACED/REtAIREVO COMPLETE TESTING. // ((f REPAIRS: LABOR:, PARTS'INTALLED : x NAM: TITLE,: SIGNATURE THE ABOVE NAMED PERSON:TAKES FULL RESPONSIBILITY OF NOTIFYIlNIG 6-- THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF ANY FINES` OR PENALTIES OCCURING. FROM NON- COMPLIANCE. A COPY OF THIS DOCUMENT HAS BEEN LEFT "ON -SITE FOR YOUR CONVIENENCE. I "l p2 ,5s Appendix VI Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httO:Nwww.waterboards.ca.aov.) MONITORING SYSTEM CERTIFICATION ForUse ByAYJurisdhrdons Wdhin the State of Callfomia Authority Cited. Chapter6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, CalHomia 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 ofthis forth must be provided to the tank system owner /operator. The owner /operator mustsubmit a copy of this forth tothe local agency regulating LIST systems within 30 days of test date. A. General Information Fadlity Name: _ Bakersfield City Police Dept Bldg. No.: Site Address: 1001 Truxtun Ave, City: Bakersfield Zip: Facility Contact Person: Contact Phone No.:( Make/Model of Monitoring System: Vesder -Root TLS35o Date ofTesting /Servicing: 10 t 11 t2010" B. inventory of Equipment TestedlCertified f`Ann4 Min K- M I vrirnrn ero,.rmn nn,,:n.ne.A I..a..n 1nAlnn...lwe.l. Tank ID: 87 UL Tank 10: X In -Tank Gauging Probe. Model: Mao. In -Tank Gauging Probe. Model: X Annular Space orVaultSensor. Model: FRPAnnular Sensor AnnularSpace or Vault Sensor. Model: X Piping Sump / Trench SeraMs). Model: 208 D Piping Sump /Trench Sensor(s). Model: 0 FIN Sump Sensor(s). Model: FlII Sump Senson(s). Model: X Mechanical Una Leak Detector. Model: PW Mechanical Una Leak Detector. Model: Electronic Une Leak Detector. Model: Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: TankOverfill / High -Level Sensor. Model: D Other (specify ui enltype and model In Section E on Page2). Other and model In Section Eon Page 2). TanklD: TanklD: In -Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: AnnularSpace or Vault Sensor. Model: Piping Sump/ Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: Fill Sump Senaor(s). Model: fig Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: Electronic Una Leak Detector. Model: 0 Electronic Line Leak Detector. Model: Tank Overfill / Hlgh-Lavel Sensor. Modal: Tank Overfill / High -Level Senior. Model: Other ul mars typeand model In Section E on Page 2). Othe=222.2giMerdtype and model in Section Eon P 2 . DlspeoaerlD: 1 Dispenser ID,. X Dispenser ContainmentSemon(s). Model: Stand Atone 0 Dispenser ContainmentSensor(s). Model: X Shear Valva(s). 0 Shear Valve(s). 0 Dispenser Containment Floats and Chain(s). 0 Dispenser Containment Floa a and Chains . Dlspernsw ID: 2 Dlsponm ID: 0 Dispenser ContainmentSensor(s). Model: Stand Alone Dispenser ContainmentSensor(s). Model: 0 Shear Vatve(s). 0 Shear Valve(s). Dispenser ContainmentFloats and Chains . Dls Contalnrthem Fbat s and Chain(s). Dispenser 111. Dispenser ID,. Dispenser ContainmentSensor(s). Model: Disperser Containment Sensor($). Model: Shear VOW($). D Shear Vatva(s). 0 DispenserContainment Fl s and Chains Dispenser Containment Flo s and Chain s . m aretarnnry conuuns more canna or aispensers, capy msmrrn. atauaa mmrnauon mr every ranK ens aspenser at ate racuny. C. Certification - 1 certify that the equipment Identified In this document was inspeemdiserviced In accordance with the manufacturers' guidelines. Attached to this Certification Is information (e g. manufacturers' chwAllsts) necessary to verity that this Information Is correct and a Plot Plan showing the layout of monitoring equipment. For any equipmentcapable of generating such reports, I have alsoattached a copy ofthe report; (checkaAthatapply): 0 System set-up Alarm htatory report Technician Name (pnrd): BruceW. Hinslev Signature: - 4 r Certification No.; A26212 License. No.: 921733 A HAZ Testing Company Name: Cal,-Valley Equipment Phone No :(6811327 -9341 Testing Company Address: 3500 Gllmore Ave. Bakersfield. Ca 93308 Date ofTesting/Servicing: 10 / 11 / 2010 Monitoring System Cartiaeation Page 1 of4 12107 1 2/21/07