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�/ RECa V m MONITORING SYSTEM CERTIFICATION JUL 1 12005 For Use by All Jurisdictions within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Codf"6W# .5. HEAMj This form must be used to document testing and servicing of monitoring equipment. A separate certifrcatiohqW;5ER&P& prepared for each 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. 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 Information Signature: Facility Name: YELLOW TRANS. Bldg. No.: Site Address: 1535 E. PESCADERO AVE Ci :TRACY I Zi :95376 Facility Contact Person: RICHARD Make/Model of Monitoring System: VEEDER ROOT-TSL250I Model: MAG 1 I Contact Phone No.: ( ) I Date of Testing/Servicing: 4-4-05 B. Inventory of Equipment Tested/Certified Check the an propHate boxes to indicatespecific equipment inspected/serviced: Tank ID: #1 ANTI FREEZE Signature: Tank ID: #2 Gear Oil License: 814027 Zln-Tank Gauging Probe. Model: MAG I Zln-Tank Gauging Probe. Model: MAG 1 Z Annular Space or Vault Sensor. Model: 302 Z Annular Space or Vault Sensor. Model: 409 Z Piping Sump / Trench Sensor(s). Model: 205 Z Piping Sump / Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: _ [IFill Sump Sensor(s), Model: FlMechanical Line Leak Detector. Model: _ ElMechanical Line Leak Detector. Model: ElElectronic Line Leak Detector. Model: _ ElElectronic Line Leak Detector. Model: _ Z Tank Overfill / High -Level Sensor. Model: _ Z Tank Overfill / High -Level Sensor. Model: OPW ❑ Other(specify equipment a and model in Section E on Pae 2). ❑ other(specify equipment type and model in Section E on Pae 2). Tank ID: #3 MOTOR OIL Tank ID: #4 WASTE OIL Zhi-Tank Gauging Probe. Model: MAG 1 ZIn-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 Z Annular Space or Vault Sensor. Model: 409 Z Piping Sump / Trench Sensor(s). Model: 205 Z Piping Sump / Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: _ ❑ Mechanical Line Leak Detector. Model: _ ❑ Mechanical Line Leak Detector. Model: _ ❑ Electronic Line Leak Detector. Madel: _ ❑ Electronic Line Leak Detector. Model: _ Z Tank Overfill/ High -Level Sensor. Model: OPW Z Tank Overfill / High -Level Sensor. Model: OPW ❑ other(specify equipment a and model in Section E on Page 2). ❑ Other (specify ui ment type and model in Section E on Pae 2). Dispenser ID: Dispenser ID: _ _ ❑ 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). ❑ Dispenser Containment Floats and Chain(s), ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: _ ❑ Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). If the facility contains more tanks or dispensers, copy tnta roaninclude mmrmauun .on c.c� y .a.... a..0 u............•v. 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 the information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, l have also µ.--1, -11 4-1 A,1- 671 avctpm cpt-nn IRI Alarm history report Technician Name(print): Roy WALKER Signature: Certification No: 4307 License: 814027 Testing Company Name: Shirley Environmental Phone No.: 909-476-7443 Address: Date of Testing: 44-05 rage t ins Monitoring System Certification CUPA COPY 03/01