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MONITd'RING SYSTEM CERTIFIOkTION For Use 13y All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter/6,Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A se arate certification or re ort must be areedd for each monitoring system control panel by the technician who performs the work. A copy of thi t*tP9 p1pw system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST syste s, ghin 30 aAFI i;i:, ii%Ci cOJ tTY days of test date. E N V I R o h I i E<l r A L A. General Information HEALTH DEPARTMENT Facility Name: G.I.Trucking Bldg.No.: Site Address: 7611 S.Airport Way City: Stockton Zip 95206 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: Veeder-Root TLS 350 Date of Testing/Servicing: May 15,2006 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment inspected/serviced: TanklD: q1 DIESEL TanklD: In-Tank Gauging Probe. Model:847-390-108 ❑ In-Tank Gauging Probe. Model: (x)Annular Space or Vault Sensor. Model:794330-302 Q Annular Space or Vault Sensor. Model: (x)Piping Sump/Trench Sensor(s). Model:794380-208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model _ (x)Mechanical Line Leak Detector. Model:Fe Petro MLD-D ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Ll Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Pae 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: M2 Tank ID: ( )In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui ment type and model in Section E on Pae 2). ❑ Other(specify equipment a and model in Section E on Page 2). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). )Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). M Dispenser Containment Floa s and Chain(s). Bravo Box ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: ______ _ Dispenser lD: O Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ODis enser Containment Floats and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). *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 inspected/serviced 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): (x)System set-up (x)Alarm history report Technician Name(print): Eric Molgaard Signature.: Eric Nofgaard Certification No.: ICC 5250200-UT,Veeder-Root AZ7985 License No.: 309105 Testing Company Name: STOCKTON SERVICE STATION EQUIPMENT CO.INC. Phone No 209-464-8333 Site Address: 7611 S.Airport Way,Stockton,CA 95206 Date of Testing/Servicing: May 15,2006 Page I of 3 03/01 Monitoring System Certification