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MONIARING SYSTEM CERTIRPATION VED 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 Code of Reg€Ia sz ,z This form must be used to document testing and servicing of monitoring equipment. A separate certification or report §.'or each monitoring system control panel by the technician who performs the work. A copy of this form must be provide owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of tesB A. General Information Facility Name: Dameron Hospital Bldg. No.: Site Address: 526 W. Acaia St. City: Stockton Zip: Facility Contact Person: IUGR Contact Phone No.: ( Make/Model of Monitoring System: Date of Testing/Servicing: 4/4/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui inent ins ectedlserviced: Tank in Diesel Tank ❑ 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: L.D2000 ❑ 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/'French 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 f High-Level Svmm. W del. ❑'lank O Mfill f High-u-gZl SVfr.,V1. 34,68•. ❑ 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). ❑ Shear Valve(s). ❑ Dispenser Contairiment Hoa[(s)and Chain's). ❑F ispeaserContainment float(s)and Chairn(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). LEO] Shear Valve(s). El 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 of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report; (check all that apply): � Syst ❑ Alai history report Technician Name - ��SbaionTestinga, -7j — Signature: Certification_No.: License. N o.: 962520 ----------- Testing Company N : liervvice -- -- -- -- Inc. Phone No.:(209) 46"577 Testing Company Address: PO Box 31465 Stockton, Ca 95213 Date of Testing/Servicing: Page 1 of Rev(2/08)