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Moni,bgj,qg.,.5iyA C . gjavdtion Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations bis -form -must be -used toAlacument_testiug-and servicing of monitoring _equipment. Separate certifications or reports must be repared for each monitoring system control panel by the technician who perfroms the work. A copy of this form must be provided t le tank system Owner / Operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems rithin 30 days of test date. A. General Information acility Name: Yellow Transportation TCY Bldg: _ ite Address: 1535 E. Peseadero Ave. City / State SET Job#: T4 035427 acility Contact Person: Richard Smith Contact Phone No.: lake / Model of Monitoring System: Veeder-Root TLS -250 B. Inventory of Equipment Tested or Certified Check the appropriate boxes to indicate equipment inspected or serviced; CA Zip: 95376 209-833-1573 Date of Testing / Servicing. 6/28/2006 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 manufacturers' guidelines. Attached to this certification is information (e.g. manufacturers' checklists) to verify 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) O System set-up ® Alarm history Technician Name (print): Robert Soto Signature: Certification No.: 006-05-0131 Licnese No.: Testing Company Name: Shirley Environmental Corporation Phone No.: (909) 476-7443 Testing Company Address: 9595 Lucas Ranch Road, Rancho Cucamonga, CA Date of Testing / Service: 6/28/2006 Tank ED Soap Tank Tank N ID Motor Oil 10,000 In Tank Gauging Probe 730 ❑ In Tank Gauging Probe N Annular Space or Vault Sensor 407 N Annular Space or Vault Sensor 407 N Piping Somp / Trench Sensor9s) 205 N Piping Sump / Trench Sensor9s) 205 ❑ Fill Sump Sensor(s) ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill / High -Level Sensor ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment type and model in Comments. ❑ Other (specify equipment type and model in Comments. Tank ID Gear Oil 6,000 Tank N ID ANTI -freeze 6,000 In Tank Gauging Probe 730 N In Tank Gauging Probe Tao N Annular Space or Vault Sensor 457 N Annular Space or Vault Sensor 407 N Piping Sump / Trench Sensor9s) 205 N Piping Sump / Trench Sensor9s) 205 ❑ Fill Sump Sensors) ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill / High -Level Sensor ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment type and model in Comments. ❑ Other (specify equipment type and model in Comments. Dispenser ID Dispenser ID ❑ Dispenser Containment Sensor(s). ❑ Dispenser Containment Sensor(s). ❑ Shear Valves(s). ❑ Shear Valves(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID Dispenser ID ❑ Dispenser Containment Sensor(s). ❑ Dispenser Containment Sensor(s). ❑ Shear Valves(s). ❑ Shear Valves(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID Dispenser ID ❑ Dispenser Containment Sensor(s). ❑ Dispenser Containment Sensor(s). ❑ Shear Valves(s). ❑ Shear Valves(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) 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 manufacturers' guidelines. Attached to this certification is information (e.g. manufacturers' checklists) to verify 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) O System set-up ® Alarm history Technician Name (print): Robert Soto Signature: Certification No.: 006-05-0131 Licnese No.: Testing Company Name: Shirley Environmental Corporation Phone No.: (909) 476-7443 Testing Company Address: 9595 Lucas Ranch Road, Rancho Cucamonga, CA Date of Testing / Service: 6/28/2006