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MONJORING SYSTEM CERT14ATION 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 ofRegulations 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. A copy of this form must b ed to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regu ays of test date. A. General Information Facility Name: City Df Stocktn ® Corp Yard SPR 2 3 ZUIZ Bldg. No.: Site Address: 1465 E. Lincoln City: Stockton 95206 Facility Contact Person: MARIA Coma 7 -5642 Make/Model of Monitoring System: TLS- 350 Date of Testing/Servicing: 4/18/2012 B. Inventory of Equipment Tested/Certified (Check theappropriate boxes to indicates ecific aqui ment ins ected/sere- d rce . L TankREGULAR nk Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: lar Space or Vault Sensor. Model: 303 ® Annular Space or Vault Sensor. Model: 303 Sump! Trench Sensor(s). Model: 208 FElectrome ® Piping Sump / Trench Sensor(s). Model: 208 mp Sensor(s). Model: ❑ Fill Sump Sensor(s). Model:anical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: onic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Overgil / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). ID: Tank ID: Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: El Piping Sump /Trench Sensor(s). Model: El 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 'I ligh-l_&Nel Sucre. Model'. ❑ Tank Ow -o ill f High-level Sensor. 3Aodzl_ ❑ Other (specify equipment type and model in Section F., on Page 2). El Other (specify equipmen�type model in Section E on Page 2}. Dispenser ID: 1/2 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s). Modef: BEI 406 Dispenser Containment Sensor(s). ,Model: BE(406 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Cham(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 7/8 =el5/6 ainment Sensor(s). Model: EI 406 ® Dispenser Containment Sensor(s). Model: EI 406 ❑ Shear Valve(s). ittrient Roat(s) and Cha$t(s)• ❑ Dispenser Contairrrnent 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). Il the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. equipment.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 ,, , generating reports, I have also attached a copy of the report; (check I� �I ��; apply): f' IYhistory report License.Technician Name Charles Ferrucci Signature: Certification No.: B37513 Testing a Company Service Staion Testing, Inc. Testing Company ' • i PO iStockton, i.. i rate Phone. of + t 12 Page 1 of 3 Rev (2/08)