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MONI?ORING SYSTEM CERTII,:ATION NOV 19 2003 For Use By All Jurisdictions Within the State of California Authormy Cited:Chapter 6.71 Health and Safety Code;Chapter 16, Divis ton 3, Title 23, California f t LT H This form must be used to document testing and servicing of monitoring equipment A separate certification grTt/1t for each monitoring system control panel by the technician who performs the work. A copy of this forth 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 dace. A. General info.--stun Facility Name:jdpree Palms Grocery Bldg.No.: Site Address: East Waterl City. Stockton Zip: 95915 Facility Contact Person: Rudy Contact Phone No.:( 209 ) 931-6048 Make/Model of Monitoring Syste*n. T " -- TU Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified %heck th�a riate boses to indicate cine ui meet Ina c€ed/strwced: Tank ID: T1 Regular Tank ID: T7 Plus 0 In-Tank Ganging Probe. Model: 0 In-Tank Gauging Probe. Model: fjd Annular Space or Vault Sensor- Model:Rnnan Fl natsw;tr 13 Annular Space or Vault Sensor. Model: EI Piping Sump/Trench Sensor(s). Model:Ronan Flontswitel $i Piping Sump/Trench Sensor(s). Model:ROtasu—FleaL swi 0 Fill Sump Sensor(s), Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector, Model: 0 Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector- Model: 0 Electronic Line Leak Detector. Model: 11 Tank Overfill/High-Level Sensor. Model:OPW 61 SOP 10 Tank Overfill/High-Level Sensor. Model:OPW fu sop 0 Other equipment=and model in Section E on 2 0 Other i Y p.M and model in Section E on EM 22. Tank ID: Tank M 0 in-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: Cl Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump I Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s)- Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 13 Mechanical Line Irak Detector- Model: 0 Electronic Line Leak Detector. Model- 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: 0 Other equipment and model in Section E on Page 2). 0 Other uipment=and model in Section E on Page 2). Dispenser ID: #7 RPgnlar Dispenser ID: W Dispenser Contaitunent Sensor(s). Model: Tnrnn TCP—TTI.0 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s)- 0 DLs22=Containment FI s and C . 0.. 0 DMpS=Containment F1 s)and Chains. Dispenser ID: #2 Plus Dispenser ID: 118 Dispenser Containment Sensor(s). Model: Tnrnn TSP—TriA 0 Dispenser Containment Sensor(s). Model: i U Shear Valve(s). 0 Shear valve(s). 0 DImiser Containment Flo s and Chain(s). 0 DispSnser Containment FSoat(s and Chains. Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). ElDispenser Containment Flo s an 1 0 RLFloats)and Chains . *Ifthe 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' gaidefines. 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 repo Ss,I have also attached a copy of the report;(check all that apply): 0 System set-up 0 r'm history r Technician Name(print): James P. Hesketh Signature: Certification No.: 33053548 License 817186 Testing Company Name: Hesketh Construction phone No: 2� 09 , 754-4452 Site Address: P.O. Boz 758, Mountain Ranch, CA 95246 Date of Testing/Servicing:11 / 14/ 03 Page 1 of 3 03181 Monitoring System Certification