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r 0 MONITORING SYSTEM CERTIFICATION v For Use By�[1P drarisdictiorls ll'ithin the State of California Authority Cited.-Chapter 6.7,Health crud 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 se crate cerkifica Ntlh�l��PP��y nr �' awt be prepared for each monitoring system control panel by the technician who perforins the work. A copy of this form must be provided to the tank system ownerloperator. The owner/operator must submit a copy of this form to the local agency reglgX # within 30 days of test date. iEldvl;j0N,MI=�;e, ` A. General Liformation HEALTH DEPARTMENT Facility Name: Sprint Stockton Bldg No.:- Site Address: 3807 Coronado Ave City;Stockton Zip:95204 Facility Contact Person: Do ye Contact Phone No.:(217 )663-9440 Make/Model of Monitoring System: Veeder-Root TLS 300C Date offiesting/Servicing: 11/7 2011 1 B. Inventory of Equipment Tested/Certified Check thea ra date hoses to Indicates ecific equipment Ins ected-Iserviced: Tank ID: Diesel AST 5000 Gal Tank ID: [Kiln-Tank Gauging Probe. Model: Mag I ❑ In-Tank Gauging Probe. Model: DAnnular Space or Vault Sensor, tviodel' 794390-420 I ❑ Annular Space or Vault Sensor. Model; QPiping Sump/Trench Sensor(s). Madel: 7943$0-208 ❑ 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: ; CI Electronic Line Leak Detector. Model: ". QTank Overfill/High-Level Sensor. Model:Flapper/V-R Ext Alarm ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecif a ui ment t e and model in Section Eon Page 2). ❑ Other(s eci ui meni a and model in Section E on Page 2). Tank ID: Diesel[IST 10000 Gal Tank ID: QIn-Tank Gauging Probe. Model: Mag i ❑ In-Tank Gauging Probe, Model: QAnnular Space or Vault Sensor. Madel: 794380-302(Stine) El Annular Space or Vault Sensor. Madel: QPiping Sump/Trench Sensor(s). Model:794384-208 ❑ Piping Sump/Trench Sensor(s), Model: ' 1 ❑ 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: ❑ Electronic Line Leak Detector. Model: _ MTank Overfill/High-Level Sensor. Model:Flapper/V-R Ext Alarm ❑ Tank Over-fill/High-Level Sensor. Model: ❑ Other (specify 2quipment=c and model in Section E on Pa a 2}• ❑ Others eci a ui ment a and model in Section E on Page 2). Dispenser ID: _ Dispenser ID: ❑ Dispenser Containment Sensor(s), Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). D Shear Valve(s). 4 ❑ Dis enser Containment Float s}and Chains}, ❑ Dis enser Containment Float s)and Chain(s). Dispenser ID: _ Dispenser ID: _ ❑ Dispenser Containment Sensor(s). -- Model: El Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Cotitainment Floats and Chain s), ❑ Dispenser Containment Floats)and Chain(s). '1 Dispenser ID: Dispenser ID: Cl Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Float s)and Chain(s). "If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification -I certify that the equipment identified In(his document vvas Inspectedlserviced In accordance with the manufacturers' guidelines. A(tached to this Certification is information (e.g, manufacturers' checklists) necessary to verify that this Information Is correct and a Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report,{cheek all that apply): x SysteM jt- s Alarm History report Technician Name(print):Peter Jauregui III Signature: ./ Certification No,:_B34641 License.No.: 70823I Testing Company Name:_Jauregui&Culver ins. Phone No.: (760) 743-0518 _ Site Address:959 W.mission Ave Escondido CA 92025 Date of Testing/Servicing:_i 1_/_7� ZQ 11 Page I of 3 03101 Monitoring System Certification