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t MONI&ORING SYSTEM CETI CATION t Use By Al'Jurisdictions Within the State of ornia Authority Cited.•Chapter 6.7,Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be 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 Facility Name: S.J.JAIL Bldg.No.: Site Address: 7000 MICHAEL CANLISS City: STOCKTON CA Zip: Facility Contact Person: RICH Contact Phone No.: ( ) Make/Model of Monitoring System: LEAK ALERT Date of Testing/Servicing: 11/14/2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicateSpecific equipment ins ected/serviced: Tank ID: DSL SOU Tank ID: DSL NORTH ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: LALS ®Annular Space or Vault Sensor. Model: LALS ®Piping Sump/Trench Sensor(s). Model: LALS ®Piping Sump/Trench Sensor(s). Model: LALS ❑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). Tank ID: Tank ID: ❑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). ❑Others eci (p fy 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). ❑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 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) to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment pable of ge erating such sports,I have also attached a copy of the report;(check all that apply): ❑System set-up ❑Alarin history rep rt Technician Name(print): David A.Winkler#5263373 Exp.03/27/10 Signature: Date of Testing/Servicing: 11/14/2008 P one No.: (209) 744-0112 Testing Company Address: 416 2ND ST GALT CA 95632 V/� Ll 17S Page 1 of 4 UN-036—1/1 www.unidocs.org Rev.01/17/08