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f County of San Diego ipk� n ys. o DEPARTMENT OF ENVIRONMENTAL HEALTH-HAZARDOUS MATERIALS DIVISION "•'No CCC w•• P.O. BOX 129261, SAN DIEGO, CA 92112-9261 16191 338-2222 FAX {6191 338-2377; 1-800-253-9933 UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION 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 installation, testing and servicing of monitoring equipment. A separate certification or report must be pre iared 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. Pian Check Number: Permit Number: A. General Information Facility Name: SPRINT NEXTEL Bldg.No.: Site Address: 3807 CORONADO AVE City. STOCKTON Zip: 95204- Facility Contact Person:JOHN McCOLLISTER Contact Phone No..(209)937-5800 x Make/Model of Monitoring System:VEEDER ROOT 300C Date of TestingiServicing:2007-11-26 B. Inventoa of Equipment Tested/Certified:Check the appropriate boxes to indicate specific equipment installed/inspected/%c"iced: Tank ID: DIESEL UST I OK Tank ID: • In-Tank Gauging Probe. Model:MAG t ❑ in-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model:794380-302 ❑ Annular Space or Vault Sensor. Model: C& Piping Sump t 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: ❑ Electronic Line Leak Detector- Model- ® Tank Overfill f High-Level Sensor. Model:.' ❑ 'rank Overfill/High-Level Sensor. M el: ❑ Other(specify equipment a and model in Section E on Pae 2). ❑ Other(specify equipment and ode[in Section F on Pae 2 . Tank ID: DIESEL AST 5K Tank ID: ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model:794390-420 ❑ Annular Space or Va ensor. Model: ® Piping Sump I Trench Sensor(s). Model:794380-208 ❑ Piping Sump I Tr h Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Se r(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechani Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Elec nic Line Leak Detector. Model: ❑ k Overfill/Iii -Level Sensor. Model: ❑ 'Tank Overfill/High-Level Sensor- Model: �' ❑ Other(specify a ui ment type and model in Section E on Pae 2). Other(specify equipment type: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). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser iD: Dispenser ID: ❑ Dispenser Containment Sensor(s). odel: ❑ Dispcnser Containment Sensor(s ode!: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containme oat(s)and Chain (s). ❑ Dispenser Containme oats and Chain (s). Dispenser ID: Dispenser ID: Dispense ontainment Sensor(s). Model: ❑ Dispens ontainment Scnsor(s). Model: ❑ Sh alve(sj. ❑ S aive(s). is ensor Containment Float s)and Chain(s), is user 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. Certification - I certify that the equipment identified in this document was installed/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 ble of generating such reports,I have also attached a copy of the report(check all that apply): ❑ System set-up ❑ Alarm histry eport Technician Name(print):Rene LeMesnager Signature: Certification No.:A26748 License No.:2 3029 DEH.HM-9301(Rev 06107/06) I County of San Diego-DEH-hazardous Materials Division