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MONLAWNG SYSTEM CEkTIFOkTION For se By All Jurisdictions Within the State of Cali ornia Authority Cited:- Chapter 6.7, Health and Safety Code; Chapter 16, Divis{on 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. IA 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: Stockton CHP Site Address: 3330 North Ad Art Road Facility Contact Person: Joe or Justin Make/Model of Monitoring System: Veeder Root TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauipment inspected/serviced- -D City: Bldg. No.: m Zip: 95215 Phone No.: (209) 943-8643 Date of Testing/Servicing: 2/6/2007 *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 ihspected/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 any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ® System set -tip ® Alarm history report Technician Name (print): Gregory Hartman Signature: Certification No.: A29881 License. No:; Uj-1640 Testing Company Name: Dialysis North Phone No.: (530) 229-1906 Site Address: 3330 North Ad Art Road, Stockton, CA 95215 i i Date of Testing/Servicing: 2/6/2007 Page 1 of 3 Tank ID: # 1 - 12,000 Gallon 87 Tank ID: ® In -Tank Gauging Probe. Model: 847390-107 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: No number ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 0794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 0794380-208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FE Petro STP MLD -E ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: Drop Tube Flap ❑ 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 Spice or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump S6nsor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical I,Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overl€11 / 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). Dispenser ID: # 1/2 Dispenser IDl ® Dispenser Containment Sensor(s). Model: 0794380-208 ❑ 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 IDI: ❑ 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 ihspected/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 any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ® System set -tip ® Alarm history report Technician Name (print): Gregory Hartman Signature: Certification No.: A29881 License. No:; Uj-1640 Testing Company Name: Dialysis North Phone No.: (530) 229-1906 Site Address: 3330 North Ad Art Road, Stockton, CA 95215 i i Date of Testing/Servicing: 2/6/2007 Page 1 of 3