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• MONITORING SYSTEM Authori 1<or i"I,ve B CERTIFICATION ty Cited. Chapter 6 7 Hecahh Sa eJPf riselictions Within the State of Ccrl for?ria } ty Code; Chapter Id piviyj n 3, Title 23, California Code o This form must be used to document testin f r each monitarin s stem control Ics by the techs;g and servicing who monitoring of f Rei,�rlatio��s system awner/operator, The ownerlo eratar must submit a co equipment se._Darate ce,tcai or re ort must be are ared p performs the work. A copy of this form must be provided to the tank days of test date. copy of this form to tate local agency regulating UST A. General Information systems within 30 Facility Name. Sprint Stockton Site Address: 3807 Coronado Ave Bldg. Facility Contact Person: Daye ��~1��--�-- City: Stockton !� Make/Model of Monitoring ~~ —_�_ Contact Phone No.: (217 )tab3.9440 t;S ystem: Veeder-Root TLS 3000 B' Inventoryof Equipment Tested/Certified of Testing/Servicing: !l /7/2014 Cheek thea ro Mete bows to indicate s ecific e Uj Tank ID: Diesel AST 5000 Gal mart U' `U g °C "er'tced: 10 In-Tank Gauging Probe, Tank ID: []Annular Space or Vault Sensor. Mode]: Mag] mFi rn Sum Model: 794390-420 ❑ In-Tank Gauging probe. P g s p/Trench Sensor(s). Model 7943$0.208 Ll Annular Space or Vault Sensor. Model: ❑ Fill Sump Sensor(s). ❑ Pim Model:z z, ❑ Mechanical Line Le Model: �— Piping Sump/']rr}t Sensor(s). Model: ❑ Electronic Line Leak Detector,, Model: ❑ Fill Sump Scnsor{s). Model,~` ❑ Mechanical Line Leak Detector. Model: �JTank Ovorlil]/High-Level Sensor. M `~ ❑ Electronic Line Leak Nfodel: 0 Other(sped -equipment oriel:Flapper/V-R Ext Alarm Deterxor. Model: Q Pment type and model ut Section E on Page 2). L❑7 T�overfill/High-Level Sem. Model: T anis ID: Diesel UST 10000 Gal other(specif eq meat ©ln-Tank Gauging Probe. Tank @: a^d tEtodel in Section E Po an ge 2). ®Annular Space or Vault Sensor. Model: Ma 1 In-Tank-'Gauging ©Piping Sttmp/Trench SensorModel: 71438U-302(Brine} Prob,�. —— ❑ Fi11 Sump Sensor (s) Model:794380-208 Q Annular Space or Vauh Sensor. Model: ❑ Mechanical Line Model: ❑ Piping Sump/Trench Samsor(s). Model: Electronic Line Leak Detecor. Model: ❑ Fill Sump Sensor(s). ❑ Mechanical Line tlodel:~—��- ©Tank Overfill/Hi Model: _�_� -- Leak Detector I-I{odcl:High-Level Sensor,Level Sensor, Model:Fla Cl Electronic Line leak Detector. ❑ Other{specify e4wpment a and peer/V-R Ext Alarm ❑ Tank Overf l]/High_�1 Mode]: ��sodel in Section E on Page 2). p O 5cgsar Mode[- Sump ID;AST Trans sump that(specify aqui and mrx�e!in Sectio-- n E on Page 2}� ❑ Sump Containment Sensor(s). Model: 794380-208 Dispenser ID: ❑ Shear Valve(s). — ❑ Dispenser Contaiarnrru ❑ Dispenser Containment Floats}and C�iairt(s) ❑ Shear Valve(n Sm`�(s) Me&l:Dispenser ID: ❑ Dis �~~~` parser Containmcot it7oat(s)and Chain(s). V LI Dispenser C011 Ainment Sensor(s), Model Dispenser ID: ❑ Shear Valve(s). ` ❑ Dis enser Containment Floa(s)and Chain(s), Q Dispenser Containment Sen ❑ Shear Valvc(s). Dispenser 10: ❑ Dispenser Containment Float s - ❑ Dispenser Cont ' - ( ) Chain(s). oatmeal Sensor(s). Model: Dispenser ID: _ ❑ Shear Valvc(s)_ —� ❑ Dis ❑Dispenser Con —`� Dispenser Cont$irunent Sensor(s). Model: taiwncnt Float s)and Chain(s}. L3 Shear Valve(s). *If the facility contains more tanks s ❑ Disponser Containment Float(s)and Cbain(s), or dispensers,copy this form. Include iormatian for eve C. Certification - I certif every tank and dispenser at the facility. y that the equipment i identified in this doctement was inspected/serviced in accordance with the manufacturers, guidelines. Attached to this Certification is intonation e, , correct and a Plot plan showing the layout of rnonitorin e ( g manufacturers checklists) necessary to verify tars' attached a copy of the report;(check all that apply) g 9Uipment. For an equipment ca able of that this information is Technician tJatne tint :P pP vl' x System s yF generating such reports,I have also (p ) peter Jauregui III larm history report Signature: Certification No.: 1334641 Testing Company Name: Li&Culver inc. Li se. No,:_70$231 Site Address: 959 W. mission Ave Escondido CA 920.25 ~— Phone No.: 760 ( ) 743-05I8 Date of Testing/Servicing:J I_/ 2014 7 Monitoring System Certification Page I of 3 0310I