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MONIT*UNG SYSTEM CERTIFI&TIOPJE(;;j=- f' <br /> For Use By All Jurisdictions Within the State of California IVE <br /> Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code KR�yeg$�ul/R+tions <br /> This form must be used to document testing and servicing of monitoring equipment. A separate certification or report m f0YCr06a���rr each <br /> 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. <br /> The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of teIRONMENTAL <br /> A. General Information <br /> FacilityName: SHANE&DAVES Bldg.No.: <br /> Site Address: 3550 HWY99 City: STOCKTON Zip: 95215 <br /> Facility Contact Person: MIKE ELIASON Contact Phone No.: (209)948-9412 <br /> Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: 313112015 <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicatespecific equipment inspected/serviced. <br /> Tank ID: 87/RED DIESEL SPLIT TANK Tank ID: RED DIESEL/87 SPLIT TANK <br /> ®In-Tank Gauging Probe. Model: MAG ®In-Tank Gauging Probe. Model: MAG <br /> ®Annular Space or Vault Sensor, Model: VR 420 ®Annular Space or Vault Sensor. Model: VR 420 <br /> ®Piping Sump/Trench Sensor(s). Model: VR 208 ®Piping Sump/Trench Sensor(s). Model: VR 208 <br /> ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: <br /> E Mechanical Line Leak Detector. Model: MLD STP E Mechanical Line Leak Detector. Model: LD2000 <br /> ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: <br /> ®Tank Overfill/High-Level Sensor. Model: FLAPPER E Tank Overfill/High-Level Sensor. Model: FLAPPER <br /> ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). <br /> Tank ID: Tank ID: <br /> ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: <br /> ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: <br /> ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: <br /> ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: <br /> ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: <br /> ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: <br /> ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: <br /> ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). <br /> Dispenser ID: 1/2 Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: <br /> H Shear Valve(s). ❑Shear Valve(s). <br /> ®Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑Shear Valve(s). ❑Shear Valve(s). <br /> ❑Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑Shear Valve(s). ❑Shear Valve(s). <br /> ❑Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification -1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have also <br /> attached a copy of the report;(check all that apply): ® System set-up ® Alarm history report <br /> Technician Name(print): RICHARD THOMAS Signature: L b �- 5 <br /> Certification No.: B34022 License.No.: 803705 <br /> Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No.: (707) 779-4999 <br /> Testing Company Address: P.O.BOX 5850, RIVERSIDE, CA 92517-5850 Date of Testing/Servicing: 3131115 <br /> Page I of 4 <br /> UN-036— www.unidocs.org Rev.01/17/08 <br />