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°ONIT SVG SYSTEM CE 'rIFIC ION ForO By All Jurisdictions Within the Stat of Califo Authority Cited. •-Chapter 6.7, Health and Safety Code; Chapter 16, Divisi n 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. -A se arate certiltt tion o i must ne e a 'lou tv, each monitoring av�tem eontro anel"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 Iagency regulating LIST systems within 30 days of test date. A. General information Facility Name: Stockton CHP Site Address: 3330 North Ad Art Road City: Facility Contact Person: Joe or Justin Make/Model of Monitoring System: Veeder Root TLS 350 B. Inventory of Equipment Tested/Certified �__._ ..a.. �.....-- •.. L..A*n +. Q niP.n a .inment inenertedkervlred47 Bldg. No. )n Zip: 95215 Phone No.: (209) 943-8643 Date of Testing/Servicing: 2/6/2007 # 1 -12,000 Gallon 87 Tank ID: In -Tank Gauging Probe. Model: ank Gauging Probe. Model: 847390-101❑ rTankD: ular Space or Vault Sensor. Model: No number ❑ Annular Spa or Vault Sensor.Model: ng Sump / Trench Sensor(s). Model: 0794380-208 ❑ Piping Sump/ Trench Sensor(s).Model: Sump Sensor(s). Model: 0794380-208 ❑Fill Sump Se rsor(s). Model: ® Mechanical Line Leak Detector. Model: FE Petro STP MLD -E ❑ Mechanical kine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic L ne Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: Drop Tube Flap ❑ Tank Overfil / 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: I ❑ In -Tank Ganging 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 Sum / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump S�nsor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical kine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronicne Leak Detector. Model: El Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). (speci,.f Dispenser ID: # 1/2 Dispenser 1 ® Dispenser Containment Sensor(s). Model: 0794380-208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). El Shear Valvd(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser ontainment Float(s) and Chain(s). Dispenser ID: Dispenser IDI: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser oontainment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser qontainment Float(s) and Chain(s). Dispenser ID: Dispenser 10: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser dontainment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valv4s). El Dispenser Containment Float(s) and Chain(s). El Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy tors Corm. tnauae tnrormauon wil c—ly taun eaiu —F—A-9 u.VAX' • •._ ,. 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 Site -Plot Plan showing the layout of monitoring equipment. For i ny equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ® System Set -i p ® Alarm history, report Technician Name (print): Gregory Hartman Certification No.: A29881 Testing Company Name: Dialysis North Site Address: 3330 North Ad Art Road, Stockton, CA 95215 Signature: Page 1 of 3 640 Phone No.: (530) 229-1906 Date of Testing/Servicing: 2/6/2007