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RECOMEDly Mon* 1 oll � rf37F 1©11 Authority Cited:Chapter 6.7,Health and Safety Code; Chapter 16,Division 3. Title 23, California Code ofRegu�at2on—s 6 2006 This form must be used to document testing and servicing of monitoring equipment. Separate certifiWffi_*W EaMbe prepared for each monitoring system control panel by the technician who perfroms the work. A copy f 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. k. General Information acility Name: Stockton,CA Switch Bldg: SET Job#: T7 036784 ite Address: 3807 Coronado Ave City/State Stockton CA Zip: 95204 acility Contact Person: Jay Lemes Contact Phone No.: 209-937-5800 lake/Model of Monitoring System: Date of Testing/Servicing: 9/1212006 B. Inventory of Equipment Tested or Certified Check the appropriate Boxes to indicate equipment inspected or serviced; Tank ID T-2 UST Diesel Tank ID T-1 AST Diesel ® In Tank Gauging Probe Mag 1 ® In Tank Gauging Probe Ma®1 ® Annular Space or Vault Sensor 302 Annular Space or Vault Sensor 420 ® Piping Sump/Trench Sensors) 288 ® Piping Sump/Trench Sensors) 208 ❑ Fill Sump Sensor(s) NIA ❑ Fill Sump Sensor(s) NIA ❑ Mechanical Line Leak Detector PLLD ❑ Mechanical Line Leak Detector NIA ❑ Electronic Line Leak Detector ❑ EIectronic Line Leak Detector ® Tank Overfill/High-Level Sensor TLS 300C ® 'Tank Overfill/High-Level Sensor TLS 3000 Other(specify equipment type and model in Comments. ❑ Other(specify equipment type and model in Comments. Tank ID Tank ID ❑ In Tank Gauging Probe ❑ In Tank Gauging Probe ❑ Annular Space or Vault Sensor ❑ Annular Space or Vault Sensor ❑ Piping Sump/Trench Sensors) ❑ Piping Sump/Trench Sensors) ❑ Fill Sump Sensor(s) ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill f High-Level Sensor ❑ Tank Overfill/High-Level Sensor ❑ Other(specify equipment type and model in Comments. ❑ Other(specify equipment type and model in Comments. Dispenser ID NIA Dispenser ID NIA ❑ Dispenser Containment Sensor(s). ❑ Dispenser Containment Sensor(s). ❑ Shear Valves(s). ❑ Shear Valves(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID Dispenser ID ❑ Dispenser Containment Sensor(s). ❑ Dispenser Containment Sensor(s). ❑ Shear Valves(s). ❑ Shear Valves(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID Dispenser ID ❑ Dispenser Containment Sensor(s). ❑ Dispenser Containment Sensor(s). ❑ Shear Valves(s). ❑ Shear Valves(s). ❑ Dispenser Containment Float(s)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 manufacturers' guidelines.Attached to this certification is information(e.g.manufacturers' checklists)to verify 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 of the report(check all that apply) ® System set-up Alarm history Technician Name(print): Fabian Gomez Signature: Certification No.: A24225 License No.: Testing Company Name: Shirley Environmental Corporation Phone No.: (909)476-7443 Testing Company Address: 9595 Lucas Ranch Road, Rancho Cucamonga,CA Date of Testing/Service: 9/12/2006 Monitorine Svstem Certification Pave 1 of 3 3101