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Annual System Test Report <br />MONITORING SYSTEM CERTIFICATION <br />f or (Ae 8)- All Jariadictiuns Within the State t?t Calilurniu <br />llahrriri• 01ed.- ['hunter 6.'• Health and.&fett-Calt; Chapter 16. Dis•mion 3. Title 23. Culilixniu Crule uJ Rekuluuons <br />I <br />I hts tiwm must he used Io dtxurncnl testing and scn icing o(nutnikxmg cquipmclu 11' meet (hart one monitoring sgxlcm atnlrul p:mrl is msmllsal at <br />the laciIits, s,\1SpiIfdlS 44)►Jwtion or rerun mus he r rrJ lin each monihtrift .jjgcnl eon truI panel by the Imfinician %t ho performs thrk <br />e wo <br />A cop\ of this form must be pros ided 14, the uutk ysem owner operator. The oMncr itperator mus suhmit a cup. oI IN, titan to the I(xal ageme <br />rcgulaling LiSI syslrms scuh tt to day+.,1 by date Instructions arc printed ctrl the hack of thit page. <br />A. General Information <br />facilitN Name: CAARNG STOCKTON AASF 112 <br />Site Address. 2000 Stinson Rd. <br />I aciitN Contact Persue: Luis Pajam — <br />Make Model of Monitoring S%stern: Vseder Root TLS 350 <br />R. Inventory of Equipment Tested/C'ertifled <br />( hrclk the ■ppropriale holes to 1rKkatc 1pMfit eglspaKat irapecicd'xnlctd <br />Bldg. No.: <br />City: Stockton Lip: 95206 <br />_ C'ontact Phone No.: (209)983.53.38 — <br />Date of Testing'Scn icing: 7128/2016 <br />Tut 1D- 1 F-24 1SK UST <br />Tank ID 2 F-24 20k AST <br />Gauging in -Tank u ging 11nthr <br />M -lel Mall -7 <br />® In I an► Gaatring Prr.It <br />Muiki Map -7 <br />Q Annular %Pana •n %-11 tions <br />\Lila alp <br />�' L.nulm `+{wcc �� %salt %cr.,.n <br />%1,W1 420 <br />® Piping sunyt Ircnch \rtnini,i <br />%I.slrl 2N <br />❑ hpulg sump trench 4rtue(s> <br />thrki <br />❑ 1.11 sump vrmit11s1 <br />%hsk-1 <br />❑ Idl %ump lcvv xvw <br />%ldcl <br />❑ W,:hanwal I me I cal, 1 occum <br />M,xkl <br />❑ k1cchantcal I im Leal, DaLN-1vr <br />tkski. <br />❑ I'Ic'Inow I'm I rak r]nn-nx <br />M,,&I <br />❑ I.kctninte I Inc I cak 1)ctcm" <br />%kAd ..—__.._— <br />❑ tank ()scrfrll Iligh-1 ccrl vcri"I <br />M,akl <br />❑ bank overfill % High -tenet srnsw <br />%Ldm !-- <br />❑ Wits Ilpectrs cqurpntna I)pc and rmakl to % ,otm F to Parc _'l <br />❑ Odw4specith cyugancsa tspc =W m.drl m tectum I <br />Task ID: <br />Tarek ID <br />❑ In-Iask Gauging fNvk <br />%III&A <br />❑ In -lank (taugina Prnhc <br />\kt.kl <br />❑ N\nmdw %pax of %duh %caster <br />%I.rkl <br />❑ Annular spacc or Vault tscn— <br />%kdci <br />❑ Piping lump' trench Srnsixtsl <br />%I.skl <br />❑ Upon@ sump I tench %cn.nnsl <br />%hW- <br />❑ rill Sump %cmarrsI <br />Mull <br />❑ Id' %,imp %--o <br />%I11dc1 <br />❑ %/cchu ical I inc Leak IXteeke <br />Mrwk-I <br />❑ Nkchani,A I enc 1 cak [Mecum <br />\ktdcl <br />❑ l.kctrmw I.mc I.cak Iktrow <br />%k,dcl <br />❑ I kcuoarc 1 stir I ca► Daccl.r <br />%hnkl <br />❑ Trak ()sglill • HtRIt-l.c+cl vcnxc <br />MttJcl <br />❑ Junk (hcrfdl , Ilorb-I.rccl %crn,tr <br />%h%kl <br />❑ (JIM tspeeds cqutpmcni type and mtdcl to scctk.n I ,m Iraq _ 1 <br />❑ (ether (speed% cqueatacnt hpc and Intdcl in witon t on I'agc :1 <br />Disperser ID REEL UDC <br />Dispenser ID: TRANS SUMP <br />® Ih,pcn.cr t'trnrnrrleru Srn,rrlsl <br />%I,Kkl 200 <br />®I)vpemcs (.mcunmcni %cmt,nsl <br />% idcl 206 <br />❑ %hear %ahcysl <br />❑ vicar %ahctc) <br />❑ Ihsptma l crnarnrricru 1 ktatt s t and ( harm s t <br />❑ I h ipenser l mlautmenr I kta11 s i and <br />l hath s t <br />Dispenser ID. <br />Dispenser ID <br />❑ Ih%pemer r. ,aaarnntcnt 4mral,t <br />Ahtrkl <br />❑ Ihspenwr (•mtanment vcmonsl <br />M.tJcl <br />❑ Shear vainsi <br />❑ Shea Vatsos1 <br />❑ Ih;patsa l,ttntatnmcnt 1I,v11rs1 and(hanu,l <br />❑ IliyKnser C.mlamnxtn Fnta(si arrl(hamlcl <br />Dispenser ID <br />Disperser ID: <br />❑ Di perms t <br />❑ I)tslxrner Lor"A ttcm %cn—",l <br />M,.JcI <br />❑ %hc;r %alcclit <br />❑ Shcan %alsasl <br />❑ IAspenvr t mtumnent I kan,i aid ( haini,i <br />❑ Dispenser L orstarnntent I k,arsi ArJ t)tanteo <br />C. Certification - 1 rertifs that the equipment identified in this document wm inspect, iced in accordance with the <br />manufacturers guidelines. Attached to this ('ertificstion is information (e.g. manufacturers' ISIS sar% to serifs that Ibis <br />information k correct and a Site plot Plan showing the layout of monitoring a ulpmenl. For u' clot bit of generating such <br />reports. 1 base also attached a copy of the report: (cher•4 all tlrer atpphl: Syslem set- report <br />Technician Name (print): t M10 Olson Signature: <br />CxrtlticaHon ho : A26661 – f Lung.No.. 612636 <br />Testing Company Name: Tsnk Tian Inc, Phone No.: (US) 6684 067 <br />Site Address: 2745 Sherwin Ave 06 Ventura CA. 93003 trate of I L-Aing.'Sen icing 7/26/2016 <br />Pare 1 of 3 <br />17 <br />