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0 MONITORING SYSTEM CERTIFICATION 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' �a �� This form must be used to document testing and servicing of monitoring equipment. A s_parate certificatior�� ® t`(`"ared 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: CHP Stockton Site Address: 3330 N. Ad Art Rd. Facility Contact Person: Linh Ngo Make/Model of Monitoring System: Veeder Root TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Phone: City: Stockton Bldg. No. Zip: 95208 Date of Testing/Servicing: 2-26-10 Tank ID: 87 Gasoline Dispenser ID: ® Dispenser Containment Sensor(s). Model: 794380-208 Tank ID: ® Shear Valve(s). ® In -Tank Gauging Probe. Model: 846390-107 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 794390420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: STP MLD ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: Drop Tube ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pae 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 a and model in Section E on Pae 2). ❑ Other (specify equipment a and model in Section E on Page 2). Dispenser ID: 87 Gasoline Dispenser ID: ® Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser 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). ❑ Dis enser 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). I ❑ 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): ® System set-up ® Al a Technician Name (print): Brian Halfwassen Certification No.: A24602 Testing Company Name: California Hazardous Services, Inc. Site Address: 3132 W. Adams Street, Santa Ana, CA 92704 rm h>story report Signature: License o,: 734854 Phone: (714) 434-9995 Date of Testing/Servicing: 2-26-10 Page 1 of 3 11/06