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PETRO-IfCHZ ENVIRONMENTAL'CRVICES F?1FQEjVSD <br /> MONITORING SYSTEM CERTIFICATION <br /> For Use By All Jurisdictions Within the State of California JUIV 2 5 2012 <br /> Authority Cite&Chapter 6 7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Regulations <br /> rNV1F?0N <br /> This form must be used to document testing and servicing of monitoring equipment.A sMarate certification or re i"" <br /> v M"Ma vi*s* <br /> for each monitoring_system control panel by the technician who performs the work. A copy of this form must be. rR90WWMk <br /> pZ1 <br /> system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 <br /> days of test date. <br /> A. General Information <br /> Facility Name: UNITED RARCEL SERVICE Date of Certification/Testing Services:6/7/2012 <br /> Site Address: 1532 NOR TH BROADWAY City/State:ET—OCKTON.CA Zip:95205 <br /> Facility Contact Person:KASI MONTGOMERY-PLANT ENGINEERING Contact Phone No.: (916)708-661 <br /> Make of Monitoring System:VEEDER-ROQT_TLS-350 Model No.:0847090-022 Serial No.:OAVAILMLE <br /> B. Inventory of Equipment Tested/Certified <br /> Me rCheck thea ro. . boxes to indicate sF±�iflc equipment in!pected/serviecd: <br /> Check <br /> Tank ID: jLL.D <br /> an ffffL <br /> Annular Space or Vault Sensor. Model: U:Lej_det&ot#202 Tank Comments: <br /> Piping Sump/Trench Sensor(s). Model: L2:Veeder-Root#208 <br /> Mechanical Line Leak Detector. Model: YRorjLsg 22IM2000 <br /> 0 Electronic Line Leak Detector. Model: <br /> U Tank Overfill/High-Level Sensor. Model: <br /> 0 Other(specifX equ!paent pTe and model in Section E�P e 2). <br /> Dispenser ID- N 1-2 DIESEL Dispenser Comments: <br /> Dispenser Containment Sensor(s). Model:Vgeder-Root M 001 <br /> Shear ValvS(s). <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certirkation-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is <br /> correct and plot plan showing the layout of monitoring equipment For any equipment capable of generating such reports,I have also <br /> attached a copy of the report;(check all that apply): 10 System set-up Alarm history report <br /> Technician: 'Dan Zeman Signature <br /> Company Name:PETRO-TECHZ EnvironMeptal Services Company Address: P.Q.Box 294 rad' CA 95967-2_941 <br /> Company Phone and Fax No.:JLM 680-2905 Fax:(5301872-8648 SWRCBT ank Tester License No.:#28-1535 <br /> Veeder-Root Certification No.:A32807' Exp.:4/2014 ICC,CA UST Service Technician Certification No.:5243781-UT <br /> Date/Time of Certification Services:617/2012 9:00 am Inspector Present(Name):Jeff Wong-S.J.Co.E.H.D. <br /> Page 1 of 5 <br />