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MONIARING SYSTEM CERTIFY T ION For Use By Ail Jurisdiclions With in 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 egaipment.A separate certificatagM or M-01t must be aced for each monito system control Anel by the technician who performs the work A copy of this farm must be provided to the tank system owneeoperator. 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 Infonnation Facility Name: Rancho San Miguel Bldg,No.: Site Address:_1427 Airport Way City:_Stockton _ 7_ip:_95205 Facility Contact Person: Gilbert Silva Contact Phone No_' (209___)942 2840 Make/Model of Monitoring System:Weeder-Root TLS 350 M _ Date of Testing/Servicing: 6/17105 B. Inventory of Equipment TestedlCerkified Check the aepropriRte boxes to Indicates Ific a of ment ins ectedhRrvieed: Tank TD: Unloaded Tank ID: 0 In-Trtnk Cmuging Probe_ Model,847390109 Cl In-Tom Gauging Probe. Model: X ular Space or Vault Sensor. Model:794380-420 ❑ Annular Sp©ce or Vault.Sensor. Model- Mgng Sump 11 ranch Scrasor(s). Modal: 794380-208 ❑ Piping Sump f Trench Sensor(s). Model: M Fill Sump Scnsor(s)- Model:_794380-208 0 Fill Sump Scnsor(s). Model: 0 Mechanical Linc Leak Detector. Model:_FX2V __ ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: U Electronic Line Leak Dcteator. Model: 0 Tank Overfill 1 High-Level Sensor. Model'_OPW61 SOEVR ❑ Tank Ovefill(High-Leve)Sensor. Model: Other s cci ui ment a and model in Section E on P c 2 d other s eci _.Nuipment typc and model in Section E on Pap 2). Tank ID:_'Super Tank ID: ®In-Tank Gauging Probe. Model: 847390-109 _ ❑ In-Tank Gauging Probc. Model. ©Annular Space or Vault Sensor. Model:_shared w./unloaded 0 Annular Space or Vault Sensor. Madel: El Piping Sump/Trench Scnsor(s). Model: 794380-208 ❑ Piping.Sump/Trench Sensor(s). Model: ®Fill Sump Scnsor(s). Model: 794384-208 ❑ Fill Sump Sengor(s)• Modcl; -__..-- 0 Mechanical Line Leak Detector. Model:–FX2V ❑ Mechanical Line Leak Dctccmt. Model.: 0 Electronic line Leak Detector_ Model: ❑ Electronic Linc Leak Detector. Model. Z Tank Overfill/High-Level Sensor. Model:_OPW61 SOI VR ❑ Tank Overfill/High-Level Sensor. Model: Other coil a ui merit and model in Scetion E on P e 2 ❑ Other s eci a ui mcnt type and model in Section Bon PaRe 2 Dispenser ID:_1./2 Dispenser TD: ®Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model' 0 Shear Valve(s). 0 Shear Valve(s). El Dispenser Containment Float(s) and Chain (s). ❑ Dispenser Containment Floats and Chains. Dispenser TD:_3/4 Dispenser ID: IRI Dispenser Containment Sensor(s). Model:W794380-208, ❑ Dispcncer Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valvc(s). 0 Dispenser Containment Flogs and Chain -.- 0 Dispenser Containment Floats and Chain (s). Dispenser iD._5/6 Dispenser TD, 21 Disposer Containment Sensor(s). Model:_794380.208 ❑ Dispenser Containment Sensor(-.), Model: M Shear Valvc(s). 0 Shear Valvc(s). MV,spanser Comainmcnt Float(s) and Chain (s). 1 0 Dispenser Containment Floats and Chain (s). *If the facility contains more tanks or dispensers,copy this foam, Include information for every tank and dispenser at the facility, C. Certificat][00-T eertlfy that the equipment Identified in this document was inspettedlserviced in accordance with the manufacturers" guidelines. Attached to this Certification is information (e g. manufacturers' checklists) netes9Rry to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of Wnerating such reports,I have also attached a copy of the.report;(check all thas appty): x System set-up 14rarm histo ♦apart Technician Name(print):_David Martin Signature: -- - Certification No.: 006-05-0498 License.No.: A304147 Testing Company Name:_Franzen Hill Phonc No.:(559�)_6882977� SiteAdd.ress: 1100 N! st Tulare 93274 Date of Testing/Servicing: 6/1.7105 1E -(136-114 Page 1 of 3 Rev-06/54A3