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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited:-Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 13,California 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 of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. offfis page. A. General Information Facility Name: Sprint Stockton Bldg.No.: Site Address: 3807 Coronado Ave City:Stockton Zip:95204 Facility Contact Person: Frank Contact Phone No.:(217 )390-1306 Make/Model of Monitoring System:Veeder-Root TLS 300C Date of Testing/Servicing: 10-27-17 B. Inventory of Equipment Tested/Certified Check the appropriate bores to indicates edfic a ul meat las eeted/servlcedr Tank ID: Diesel AST 5000 Gal Tank ID: ®In-Tank Gauging Probe. Model: Mag 1 ❑ In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390-420 ❑ Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Semor(s). Model: 794380-208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: l] Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: LI Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor, Model:Flapper/V-R Ext Alarm ❑ Tank Overfill/High-Level Sensor. Model: 3 Other(specify equipment a and model in Section E on Page 2). ❑ Other(!Eecify e i meat type and model in Section E on Page 2). Tank ID: Diesel UST 10000 Gal Tank ID: Ella-Tank Gauging Probe. Model: Mag 1 ❑ In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794380-302(Brine) ❑ Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Semor(s). Model:794380-208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: l7 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model:Flapper/V-R Ext Alarm ❑ Tank Overfill/High-Level Sensor. Model: LI Other(specify equipment a and model in Section E on Pe 2). ❑ Other (Tec' equipment type and model in Section E on Pa 2 . Sump ID:AST Trans sump Dispenser ID: U Sump Containment Sensor(s). Model:_794380-208 ❑ Dispenser Containment Seasor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: - ❑ Dispenser Containment Sensor(s). Model: 11 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: U Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chains. ❑ Dis enser Containment Floats and Chain(s). -If the facility contains more tanks or dispensers,copy this formrlfuclude information for every tank and dispenser at the facility. C. Certification-I certify that the equipment identieed 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 correct and a gke-Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): r System set-up I Alarm history report Technician Name ( ir}(.L ter Jauregui III Cert^ Nn..- Signature: n.:Signature: Certification No.: B34641 License.No.: 708231 Testing Company Name:_Jauregui&Culver inc. Phone No.: (760) 743-0518 Site Address: 959 W.mission Ave Escondido CA -92025 Date of Testing/Servicing: 10-27-17 Page 1 of 3 - 03101