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Appendix VI <br /> (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httr://www.waterboards.ca.aov.) <br /> MONITORING SYSTEM CERTIFICATION <br /> For Use By All Jurisdictions Within the State of California <br /> Authority Cited., Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of <br /> Regulations <br /> This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each <br /> monitodng system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. <br /> The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. <br /> A. General Information <br /> Facility Name:SPRINT STOCKTON Bldg.No.: <br /> Site Address: 3807 CORONADO AVE City:STOCKTON Zip:95204 <br /> Facility Contact Person:KEN CARR Contact Phone No.:(209)937-5800 <br /> Make/Model of Monitoring System:VEEDER ROOT TLS 300C Date of Testing/Servicing: 11/9/2009 <br /> B. Inventory of Equipment Tested/Certifled <br /> Check the appropriate boxes to indicate specific equipment inspected/serviced: <br /> Tank ID:EMERGENCY GENERATOR,DIESEL AST 5,000 GAL Tank ID: <br /> J In-Tank Gauging Probe. Model:MAG 1 0-x In-Tank Gauging Probe. Model: <br /> J Annular Space or Vault Sensor. Model:794390320 (]v Annular Space or Vault Sensor. Model: <br /> J Piping Sump/Trench Sensor(s). Model:794380-208 Q Piping Sump/Trench Sensor(s). Model: <br /> Fill Sump Sensor(s). Model: [v] Fill Sump Sensor(s). Model: <br /> Mechanical Line Leak Detector. Model: ® Mechanical Line Leak Detector. Model: <br /> 71 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: <br /> J Tank Overfill/High-Level Sensor. Model:V/R EXT ALARM [0 Tank Overfill/High-Level Sensor. Model: <br /> Other(specify equipment type and model in Section E on Page 2). v Other(specify equipment pe and model in Section E on Page 2). <br /> rank ID:EMERGENCY GENERATOR,DIESEL UST 10,000 GAL rank ID: <br /> J In-Tank Gauging Probe. Model:MAG 1 :w] In-Tank Gauging Probe. Model: <br /> J Annular Space or Vault Sensor. Model:794380-302(BRINE) [v]Annular Space or Vault Sensor. Model: <br /> J Piping Sump/Trench Sensor(s). Model:794380-208 31 Piping Sump/Trench Sensor(s). Model: <br /> Fill Sump Sensor(s). Model: Yj Fill Sump Sensor(s). Model: <br /> Mechanical Line Leak Detector. Model: Q Mechanical Line Leak Detector. Model: <br /> Electronic Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: <br /> J Tank Overfill/High-Level Sensor. Model:V/R EXTALARM []Tank Overfill/High-Level Sensor. Model: <br /> Other(specify equipment type and model in Section E on Page 2). x Other(specify equipment a and model in Section E on Pae 2). <br /> DispenserlD: Dispenser to: <br /> (] Dispenser Containment Sensor(s). Model: ® Dispenser Containment Sensor(s). Model: <br /> [] Shear Valve(s). O Shear valve(s). <br /> v Dispenser Containment Float(s)and Chain(s). ] Dispenser Containment Floats and Chain(s). <br /> IspenserlD: DispenserlD: <br /> (v] Dispenser Containment Sensor(s). Model: [x] Dispenser Containment Sensor(s). Model: <br /> ® Shear Valve(s). [x) Shear Valve(s). <br /> M Dispenser Containment Float(s)and Chaln s. v Dispenser Containment Floats and Chains). <br /> Dispenser ID: DispenserlD: <br /> Qv Dispenser Containment Sensor(s). Model: :%] Dispenser Containment Sensor(s). Model: <br /> ® Shear Valve(s). (] Shear Valve(s). <br /> M Dispenser Containment Float(s)and Chains il Dispenser Containment Floats and Chain(s). <br /> 'If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification - I certify that the equipment identified in this document was irppeeted/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information(e.g.manufacturers'checklists)necessary to verify that this information is correct and a <br /> Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,1 have also attached a copy of the <br /> report;(check aft that apply): ❑ System set-up I (Alarm history report Qom'"}/� <br /> Technician Name(pant): Rene LeMesnager Signature:PM IL_ 1G�e r r o 4cyl,Al 9/�­ <br /> Certification No.: A26748 License.No.:203029 <br /> Testing Company Name:LeMesnager Engineering Inc <br /> Testing Company Address:_9450 B Mira Mesa Blvd_PMB 229,San Diego,CA 92126_ Date of Testing/Servicing:1119/2009 <br /> Monitoring System Certification <br /> Page 1 of 4 <br /> 1 <br />