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MONITORING SYSTEM CERTIFICfTION For Use By All Jurisdictions Within the State of California Authority Cited.-Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 23, 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 monitot-inja system control panel by the technician who performs the work. A copy of this form must be provided to the tank to the local agency regulating UST systems within 30 stem owner/operator.erator. The owner/operator erator must submit a copy of this form g y g $ Y � P P days of test date. A. General Information Facility Name; Sprint Stockton Bldg.No.: Site Address: 3 807 Coronado Ave City:Stockton Zip:95204 Facility Contact Person: Doye Contact Phone No.:(217 )663-9440 Make/Model of Monitoring System:Veeder-Root TLS 3000 Date of Testing/Servicing: 1118 12012 B. Inventory of Equipment Tested/Certilfiied Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: Diesel AST 5000 Gal 'Tank ID: ®In-Tank Gauging Probe. Model: Mag 1 ❑ In-Tank Gauging Probe. Model: IMAnnular Space or Vault Sensor. Model: 794390-420 ❑ Annular Space or Vault Sensor. Model: _ aPiping Sump i Trench Sensor(s). Model: 794380-208 ❑ Piping Sump I Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 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:Flapper/V-R Ext Alarm ❑ 'Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Pae 2). ❑ Other ispeciuipmeyt tye and model in Section F on Page 2). Tank ID: Diesel UST- 10000 Gal Tank ID: ❑x In-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: IMPiping Sump/Trench Sensor(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: U Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Ll Electronic Line Leak Detector, Model: ©Tank Overfill/High-Level Sensor. Model:Flapper/V-R Ext Alarm ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify a ui ment lyFc and model in Section E on Page 2). © Other(specify cqui inent a2c and model in Section E on Page 2}. Sump ID:AST Trans sump Dispenser ID: ❑ Sump Containment Sensor(s). Model:_794380-208 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(q)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: �� Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s), Cl Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: - - Dispenser ID: 13Dispenser Containment Sensor(s). Model: LlDispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s), ❑Dis enser Containment Floats and Clzain(s). ❑ Dispenser Containment Float s)and Chains. *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certifiiention-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 correct and a Plot Plan showing the layout of monitoring equipment. F r any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): x Syste Alarm history report Technician Name(print):Peter Jauregui III Signatttre: Certification No.: B34641 tcense.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:_11_/.8_/2012 Page 1 of 3 03101. Monitoring.System Certification