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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 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 monitoring system control panel by the technician who performs the work. A copy of this form must he 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. A. General Information Facility Name: Sprint Stockton Bldg No.:_ 1 Site Address: 3807 Coronado Ave City:Stockton Zip:95204 Facility Contact Person: Doye Contact Phone No.:(217 )663-9440 Make/Model of Monitoring System:Veeder-Root TLS 300C Date of Testing/Servicing: 11/8 12012 B. Inventory of Equipment Tested/Certified Check the approprlate boxes to indicates eeirle equipment Inspected/serviced: Tank ID: Diesel AST 5000 Gal Tank ID: 121n-Tank Gauging Probe. Model: Mag I ❑ In-Tank Gauging Probe. Model: EEAnnular Space or Vault Sensor. Model: 794390-420 ❑ Annular Space or Vault Sensor. Model: �KlPiping 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: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak.Detector. Model: Q 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 a and model in Section E on Pae 2). j ❑ Other(s eci equipment type and model in Section E on Page 2). Tank ID: Diesel UST]OOOD Gal Tank ID: Ik]In-Tank Gauging Probe. Model: Mag I ❑ In-Tank Gauging Probe, Model: 1K7Annular Space or Vault Sensor. Model: 794380-302(Brine) C.]Annular Space or Vault Sensor. Model: MxPiping Sump/Trench Sensor(s). Model.:794380-208 ❑ Piping Sump/Trench Sensors). Model: ❑ Fill Sump Sensor(s), Model: d 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:Flapper/V-R Ext Alarm ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other s ec' a ui inert g ° el' q p ftp and tnodel in Section F on Page 2). C3 Other s eci a ui inert a and model in Section E on Page 2). Sump ID:AST Trans sump Dispenser ID: ❑ Sump Containment Sensor(s). Model:_794.380-208 El Dispenser Containment Sensors). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Floa s and Chain(s). Dispenser II7: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s), Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chains). ❑ Dispenser Containment Floa s and Chain(s). P Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chains}. ❑ Dispenser Containment Float(s)and Chains, Alf the facility contains more tanks or dispensers,copy this farm. Include information for every tank and dispenser at the facility. C. Certification-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. ;Fpr any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): x Syste Alarm h' ory report Technician Name(print):Peter Jauregui III Signature: Certification NO.:_B34641 icense.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_/_$_/ Za 12 Page I of 3 03101 Monitoring System Certification