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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httn//www waterboards.ca rov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 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 testing and servicing of monitoring equipment.A separate certification or report must be prepared 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:KEN CARR Contact Phone No.: (209)937-5800 Make/Model of Monitoring System:VEEDER ROOT TLS 300C Date of Testing/Servicing: 1111012008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectediserviced: rank to:EMERGENCY GENERATOR,DIESEL AST 5,000 GAL rank ID: J In-Tank Gauging Probe. Model:MAG 1 �v In-Tank Gauging Probe. Model: J Annular Space or Vault Sensor. Model:794390-420 x Annular Space or Vault Sensor. Model: J Piping Sump/Trench Sensoria). Model:794380-208 !=*7 Piping Sump I Trench Sensor(s). Model: Fill Sump Sensor(s). Model: S] Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 2] Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: [x] Electronic Line Leak Detector. Model: J Tank Overfill/High-Level Sensor. Model:V/R EXT ALARM []Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on Page 2). -XI Other specify equipment ty a and model in Section E on Page 2). rank ID:EMERGENCY GENERATOR,DIESEL UST 10,000 GAL rank to: J In-Tank Gauging Probe. Model:MAG 1 -w] In-Tank Gauging Probe. Model: J Annular Space or Vault Sensor. Model:794380-302(BRINE) R]Annular Space or Vault Sensor. Model: J Piping Sump/Trench Sensor(s). Model:794380-208r,-]x Piping Sump/Trench Sensoria). Model: FIII Sump Sensor(s). Model: 71 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: J Tank Overfill/High-Level Sensor. Model:V/R EXT ALARM ®Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on Page 2). il Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: [x] Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensoria). Model: Qx Shear Velvets). ® Shear Velvets). FYI Dispenser Containment Float(s)and Chains. 21 Dispenser Containment Float(s)and Chain(s). IspenserlD: Dispenser ID: M Dispenser Containment Sensor(s). Model: w] Dispenser Containment Sensor(s). Model: E Shear Valve(s). Q Shear Valve(s). ® Dispenser Containment Float(s)and Chain s). 71 Dispenser Containment Floats and Chain(s). Dispenser ID: 31spenserlD: [xJ Dispenser Containment Sensoria). Model: C7 Dispenser Containment Sensor(s). Model: U Shear Valve(s). Lxi Shear Valve(s). [x] Dispenser Containment Float s)and Chain(s x Dispenser Containment Floats)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 inspectediserviced 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 of the report;(check all that apply): ❑ System set-up _Alarm history report f/n -rpt Technician Name(print): Rene LeMesnager Signature: ;lm I& Certification No.: A26748 License.No.:203029 Testing Company Name:LeMesnager Engineering Inc Testing Company Address: 9450 B Mira Mesa Blvd_PMB 229,San Diego,CA 92126_ Date of Testing/Servicing:1111012008 Monitoring System Certification Page 1 of 4 1