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JUN 07.27 AM F. 003 --- MONITORINGSYSTEM CERTIFICATION �> For Use By All Jurisdictions Within the State of California Authority Cited. Chapter a`1.7, health and,�'ctfety Cade,Chapter 16, Division 3, Title 23, California Code ofpeguraticlis �- This form must be used to document testing and servicing of monitoring equipment.A se agate certiflci o r re ort u sp _- n 4 p m st be prepared for each monitoring�colttrol panel by the technician who performs rile 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. Geueral7nformation Facility Name: Rancho SanMignel_ Bldg.No.. f Site Address:_1427 Airport Way City:_Stockton Zip:_95205 )~aeility Contact Person:—Gilbert Silva Contact Phone No-: (209 )942 2840 Make/Model of Monitoring-System:_Veeder-floor TLS 350 date of Testing/Servicing: 6/17/05 B_ Inventory of Equipment Tested/Certified Check the ro nate boxes to Indicate s etific a ui ment ins ectedtserviced: Tank 1;D- Unleaded Tank lti- M In-Tank Gaugzng probe. MWel:8473 90-1 09 ❑ In-Tank Gauging Probc. Model: l M Annular Space or Vault Sensor. Model:?94380-420 Q Annular Space or Vault Sensor, Model: 0 Piping Sump/Trench Sensor(s), Model: 794380-208 ElPiping Sump/Trench Sensor(s). Model: ilii Fill Sump Sensor(s). Model_rt794380-208 ❑ Fill Sump Sensor(s). Model, El Mechanical Line Leak Detector. Model:_FX2V ❑ Mechanical Line Leak Detector. Model: ElElcctronic Linn Leak Detector. Model: ❑ Elccfronic Line Leak Detector. Model: El Tank Overfill 1 High-Level Sensor. Model:_OP'W61 SOEVI{ ❑ Tank Overfill/High-Level Sensor. Modcl: ❑ Outer(s eci a ui rnent a and model to Section.E on P e 2)� ❑ Other(spec' 'e ui mcnt type and model in Section E on Paa 2), Tank I'b•_Super Tank ID, 0 It)-Tank Gauging Probe, Model: 847390-109 ❑ fat-Tante Gauging Probe. Madel: M Annular Space or Vault Sensor. Model--shared w/unleaded ❑ Annular Space or Vault Sensor. Model: ❑x Piping Sump/Trench Sensor(s). Model:294380-208__ ❑ Piping Sump/Trench Sensor(s). ModeL- 0 Fill Sump Sensor(s). Model:_794380-208 Q Fill Sump Sensor(s). Model- El]Mechanical Line Leak)Detector. Model: FX2V ❑ Mnckianical Line Leak Detector. Model: C1Electronic L.iaae Leak Detector_ Model: Q Electronic tine Leak Detector. Model:_ Tank Overfill/high-Level Sensor. Model:-OPW6ISOEVR _ ❑ Tan};Overfill/High-bevel Sensor. Model: _ ❑ Other(sEfcify aqui ment c and model in Section E ori P c 2). ❑ Otbcr(specify a ui ment type and model in Section E on Pae 2). Dispenser ID:_1/2 Dispenser ID: Fx7 Dispenser Containment Sensar(s). Model:_794380-208 ❑ Dispenser Containment Sensor(s). Model: M Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Disi3mser Containmcot Floats)and Chain(s- Dispenser XD:-3/4 Dispenser 1J): 12 Dispenser Containment Sensor(s). Model:_794380-208 _ ❑ Dispenser Containtnent Scmor(s). Model. (]Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Fioar(s)and Chain(s}. 0 Dispenser Containment Floai(s and Chains . Dispenser 1J?:_516 Dispenser ID: 1]Dispenser Containment Sensor(s). Model:_794380-206 ❑ Dispenser Containment Sensor(s). Model: M Shearvalve(s). ❑ Shear VaJve(s). ❑Dis enser Containment Float(s)and Chain(s), ❑ Dis cnser Contaimilent Float(s)and Chain(s). *If the facility contains more ranks or dispensers,copy this form. Include information for cvery taat,aatd dispenser aL Lbc facility C. CertifiCatioA -I certify that the equipment identified in this document was inspectedlserviced 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 O,f generating such reports,I have also attached a copy of the report-, (check all that apply)., x System set-tag Yarm histo feport Technician Name(print):_David Martin Signature: -c Z 'T Cer6facation No-:_006-05-0498 License.No.: A304147 Testing Company lvarrie:_Franzen Hili Phone No-:( 559 SiteAddress:—1100 N J st Tulare 93274 Date of Testing/Servicing:_6/17/05 —..1(Ilv:pss=1/t Page 1'of 5_-_._ Rev.06104/01