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lk MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Slate of California Authority Cited: Chapter 6.7,Health and,Safety Code;Chapter 16,Division 3, 77th 23, California Code of Regulatlons This farm must be used to document testing and servicing of monitoring equipment,A separate certification or report must be pregared for each monitories stem control panel by the technician who perforans 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: 3847 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: 11 /8 12013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate speei[ic a ui ment ins ected/servieed: Tank ID: Diesel AST 5000 Gal Tank ID: ®In-Tmk Gauging Probe. Model: Mag 1 ❑ In-Tank Gauging Probe. Model: ElAnnu far Space or Vault Sensor. Model: 794390-420 ❑ Annular Space or Vault Sensor. Model; ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Piping Sump/Trench Sensnr(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ElMechanical Line Leak Detector, Model: ❑ Mechanical Lino Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: OTmk Overfill I High-Level Sensor. Model:flapper/V-R Ext Alarm ❑ Tank Overfill/High-Level Sensor, Model: ❑ Other(spGcify equipment type and model in Section R on Pae 2). ❑ Other specify equipment tylrc and model in Section E on Page 2), Tank ID: Diesel UST 10000 Gal Tan k IID: i Oln-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. Madel: ©Piping Sump 1 Trench Sensor(s). ]Model:794380-208 Ll 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 Lcak Detector, Model: ❑ Electronic Lino Leak Detector. Model: I@Tank Overfill/IIigh-Level Sensor. Model:Flapper/V-R Ext Alarm ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify e ui ment type and model in Section E on Page 2). ❑ Other(specify equipmunt c and model in Section E on Page 2). Sump M:AST Trans sump Dispenser ID: -- ❑ Sump Containment Sensor(s). Model:_794380-2018 i ❑ Dispenser Containment Senscr(s), Model: ❑ Shear Valve(s), 1 ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chains_ ❑ Dis enser Containment Floats and Chain(s). ]Dispenser 117: Dispenser ID:___ ❑ Dispenser Containment 5cnsor(s). Model: ❑ Dispenser Containment Sensor(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: inment Sensor(s). Model: _ D Dispenser Conta ❑Dispenser Containment Sonsor(s), Model: ❑ Shear VaIve(s). ❑ Shear Valve(s). ❑Dis enser ContainmentFloat(s}and Chains. ❑ Dis enser Contsiament Float(s)and Chain(s). #If the f"ility eontains more tanks or dispensers,copy this forte. Include information for every tank and dispenser at the facility, C. Certification-I certify that the equipment identified in this document was inspected/seryiced 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 stay equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): x System Alarm history report Technician Name(print):Peter lauregui 111 Signature: t x � � Certification No,:_834641 License.No.:_7018231 Testing Company Name:_,Iauregui&Culver inc. Phone No.: (760) 743-0518 Site Address;959 W.mission Ave Escondido CA 92025 Date of Testing/Servicing:_11—/-20—/20 13 Page 1 of 3 03101 Monitoring System Certification