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MONITOUNG SYSTEM CERTIFI4WTION For Use 13y All Jurisdictions Within the State of California ��a��,.� �,,..,�� D Authority Cited.• Chapter 6. 7, Health acid Safety Code; Chapter 16, Division 3, Title 23, Californ �f�i� This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be Rrevared for each monitoring system cgntrol Dane] by the technician who performs the work. A copy of this form must be provided to the thkKsOnl o1/operator. The owner/operator must submit a copy of this forrr to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Country Club Mini Mart Site Address: 1856 Country Club Blvd Facility Contact Person: Phil Elder Make/Model of Monitoring System: Veeder-Root TLS -350 PLUS B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauininent inspected/serviced: City: Stockton Contact Phone No.: ENVIRONMENTAL HEALTH PERMIT/SERVICES Bldg. No.: Zip: 95204 Date of Testing/Servicing: Tank ID: 1 - 91 (2 compartment tank) Tank ID: 2 - 87 (2 compartment tank) ® In -Tank Gauging Probe. Model: MAG Plus [I In -Tank Gauging Probe. Model: MAG Plus ® Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: N/A ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ 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: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section Eon Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: N/A Tank ID: N/A ❑ 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: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 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). E] Shear Valve(s). ElDispenser Containment Float(s) and Chain(s). ElDispenser 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 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 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 t.f monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): Z System set-up ® Alarm history report Technician Name (print): Carl Wayne Henderson Signature:,, _ <� Certification No.: ICC: 5252923 License. No.: CSLB: 856711 Testing Company Name: HMC - Henderson Maintenance Company Phone No.: (209) 467-7573 Testing Company Address: PO Box 31325 . Stockton, CA 95213 Date of Testing/Servicing: l - Z) - 11 Page 1 of 3 Rev (2/08) I� 1C) 'N