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customer Copy Qx11OrlYl System Certlfic �,�011 Far Use byAburisdsctrons"h n State Of Ca Tide 23lifibmipCalifornra Code ofRegulations Authority Cited:Chapter 6.7,Health and Safety Code;Chop t S arate cations Or tits must be cin of monitoring egtripmen • of this form must be provided us lormmust be used to document testing and Servicing pe&oms the work. A copy The ownerloperator must submit a copy of this form w the local agency regulating UST I eared for each monitorin stem control anal by the technician who the tank system Owner f Opel ,sem Within 30 days of test date. Bldg: rr SET 3ob#: T! 028387 General Information Stockton,CA Switch CA Zip: 95204 GtyName: City!State Stockton 3$07 Coronado Ave Conti ct Phone No.: 209-937-5800 d 912812005 Ron winiams Date of Testing Servicing: Gty Contact person: Veeder Root TICS 300 C cc!Model of Monitoring SYatem: rtified .Inventory of�ExdteaTte�eq# aed nent insept�or ser� Check the appropriate 2 del Tank ID 109 Tank ID t ds1 109 od In Tank-Csauging Probe 424 ® 1. Tank Gaugmg Probe 342 Annular Space or Vault Sensor 208 M Annular Space or Vault Sensor zo8 Cg piping sump.j Trench Sensors) ® piping sump I Trench Sensors) ❑ Fill sump Sensor(s) ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Mechanical Line Leal:Detector ❑ Electronic Line LeaL Detector ❑ Electronic Line Leak Detector 7�9,M ❑ Tank-Overfill 1 py�Level Sensor Level Sensor ❑ other(specs£)'equipment type and model in Comments- Tank C+vecfrll.ITigh- ❑ other(specify equipment t}pe and model in Conmsents. Tank ID ank ID ❑ In Tank Gauging probe In Tank Craug�Probe ❑ Annular Space or Vault Sensor ❑ Annular Space or Vault Sensor ❑ p„ping sump I Trench.Sensors) ❑ piping Sump i Trench sensors) ❑ Fill sump Seasods) ❑ Fill Sump Sensors) ❑ Mechanical Line Leak-Detector ❑ Mechanical Line LeakDetector ❑ Electronic Line LeaL Detector © Electronic Line Leal:Detector ❑ Tana-Overfill i lEgh Level Sensor ❑ Tank-Overfill f Fligh-Level Sensor ❑ Other(sPccd7'equipment type and model in Comments. ❑ other(specili'equipment t<'pe and model in Comments Dispenser ID Dispeuser ID ❑ Spenser Containment Sensor(s). ❑ Dispenser Contairunent Sensar(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 V alves(s). ❑ Shear Valves(s)• ❑ Dispenser Containment Floats}and Chain(s)- ❑ Dispenser Contau►nient Fioat(s)and Chain(s)- Dispenser ID Dispenser 1D ❑ Dispenser COntaimment Sensor(s). ❑ Dispenser Containment Sensor(s). ❑ Shear Valves(s). ❑ Shear Vaives(s). El Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). tank and dispenses at the facility. If the facility contains more tanks or dispensers,G°PY this form. Include isrforn3ation for every to accordame manufacturers' ectet3lsetviced in the equipment identified in this document was checklists)to verify this information is correct i� Certification-I certify cation is information(e.g.manufacturers' ceratin such reports,I have guidelines.Attached to this certifx a ti meat.For an}'equipmeQt capable of ge g and a plot plan shon-ing the ia�'out of monitoring qE P �mn set-UP �{ Alain history also attached a copy of the report(deck aJI that apply) Loafs Na Val Signature: 03-1650 Technician Name riot : O5-0315 License No.: CertificakionNo.: cti�rlav r--=—r-0ninental Testing Phone 140.: (g09 76-7443