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A. <br />� 'ENVIRQNMLN 11A <br />1CpMDLlANGEWf7N CONf/OENCE' <br />HEALTH n . PA¢TMENT <br />MONITORING SYSTEM CERTIFICATION <br />For Use By All Jurisdictions Wrthin fhe State of California <br />Authority Cited: Chapter 6. 7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of <br />Regulations <br />This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for <br />each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system <br />owner/operator. The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. <br />General Information <br />Facility Name: Angle Gas/99 Shell Bldg. No.: <br />Site Address: <br />7700 Moreland Street <br />Facility Contact Person: Angle <br />MakelModel of Monitoring System: Veeder-Root TLS 350 <br />City: Stockton Zip: 95212 <br />Contact Phone No.: 510-552-5822 <br />Date of Testing/Servicing: 09/06/2018 <br />C. Certification I certify that the equipment identified in this document was inspectedlserviced in accordance with the manufacturers' <br />guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct <br />and a Plot Pian showing the layout of monitoring equipment For any equipment capable of generati g sac reports, I have also attached a <br />copy of the report; (check all that apply): g System set-up V Alarm, <br />Technician Name (pri <br />report <br />nt): engin a seer Signature: <br />Veeder Root No.: a37501 <br />No.: <br />Testing Company Name: Confidence UST Services Inc. Phone N�: (800) 339-9930 \1 <br />Testing Company Address: 16250 Meacham Road Bakersfield CA 93314 Date of Testing/Servicing: 09/06/2018 <br />Monitoring System Cert <br />ification <br />Page 1 of 4 <br />1?J07 <br />