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• • RECEIVED MONITORING SYSTEM CERTIFICATION DEC 08 2015 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 This form must be used to document testing and servicing of monitoring equipment.A separate certification or repCol�V D�IlispRONTAL NM NME�d^�^tT 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. A. General Information Facility Name: Sprint Stockton Bldg.No.: 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 /6/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced. Tank ID: Diesel AST 5000 Gal Tank ID: ElIn-Tank Gauging Probe. Model: Mag 1 ❑ In-Tank Gauging Probe. Model: OAnnular Space or Vault Sensor. Model: 794390-420 ❑ Annular Space or Vault Sensor. Model: MPiping 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: ❑ 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). ❑ Other(s eci equipment a and model in Section E on Pa a 2). [�(JlElectrcmic ID: Diesel UST 10000 Gal Tank ID: Tank Gauging Probe. Model: Mag 1 ❑ In-Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: 794380-302(Brine) i] Annular Space or Vault Sensor. Model: ing Sump/Trench Sensor(s). Model:794380-208 ❑ Piping Sump/Trench Sensor(s). Model: l Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: echanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: k Overfill/High-Level Sensor. Model:Flapper/V-R Ext Alarm J Tank Overfill/High-Level Sensor. Model: er(s eci a ui ment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Sump ID:AST Trans sump Dispenser ID: ❑ Sump Containment Seasons). Model:_794380-208 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). EI Shear Valve(s). ❑ Dis enser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). CI Shear Valve(s). ❑ Di, enser Containment Floats)and Chain(s). ZI Dispenser Containment Floats)and Chain(s). Dispenser to: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats)and Chain(s). ❑ Dispenser 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 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. For any equipment capable of generating such reports,I have also attached a copy ri the report; ur(check all that apply): System set-I} x Alrryr�m_history re ort Technician Name(print):Peter Jaure ui III Signalore:_� Certification No.:_ .B34641 Licens No _ 08231 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_x_6/2015 Page 1 of 3 03/01 Monitoring System Certification