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GC7f"Y ._ �+ y� Cert1f1G 01 pl'11toring Cuiifornia lations 1V 1 Cali omia Code of Far Use byAl urisd,,Ch within thDS,iSian 1,Title 23, f must be Code;Chapter I6, cations or re offs Cited:Chapter 6-7,pjealth and Safety ailment. S irate certift rovided Authority and servicing of monitoring 9 �,o y of this form ating UST ent testing the technician who perfroms the� l �l all tis form must be used to locum em control incl by of this fo e aced for each monitong operator.The ownerlapc'ator must submit a copy 5}a ;' (:l' d r U T Y the tank system Owner 1 Op ENV;R 0 i l L!�E 7 AL =stems within 30 days of test date. N E A L T}i�'3�©& H 0 ' 028387 Information Bldg: CA zip: 95204- General Stockton,CA Switch y City!State Stoekt°n iffy Narne: 209-937-5800 3807 Coronado Ave Contact Phone No.: 912812005 Address: Date of Testing 1 Servrc"'g: Ron Williams 304 C lity Contact Person: Vedder Root TLS I Model of Monitoring System: ce Certified of Equuipul TCSted or inspected or serviced; 2 dsl .Inventory a ui mein nrsp Tank ID 1°� Check the appropriate xcs to indicate q P 1 dsl In Tank�ugmg Tank ID Prone x20 109 Annular Sp ace or Vault Sensor 208 � Li Tait`GaugerQ g Probe 302 piping Sump Trench Sensors) ® Arrtmz0sfar Space or Vault Sensor ❑ Fill Sump Serrsor(s) Piping Sump French Sensors) etector Ig ❑ Mechanical Lille Leal;D ❑ Fill Sump Sensors) ❑ Electronic Line Leak Detector ❑ Mechanical Lune Leak Detector ❑ Tail.Ovef" "stl Level Sensor ❑ Electronic Line Leal-Detector 79009.001 a ui rneut h,pe and model un Cornments. Tank overfill,HighLevel Sensor ❑ other lspecif,, q p ❑ ()iher(,pee&(,peeequipment t}'pe and model in Conwrents. Tank ID [3 in Tani:Gaugirre Probe Tank 11) ------------------- [3 Space or Vault Sensor ❑ In Tank Gaagirrg Probe ❑ pipirl_Sunup'Treneh Sensors) ❑ Annular Space or Vault Sensor ❑ Fill Sump Sensors) ------- - ❑ piping Sump'Trench Sensors) - - - ❑ Mechanics!Lure Leak Detector ❑ Fill Sump sensors) Detector -Detector ah-Level❑ Electronic Line Leak Detec or MecYraaical Lune Leak-D ❑ Tail:th'ertSlt e11 Level Sensor eIIts. ❑ Electronic line Leal:Detector ❑ other(spe cif'equipmernt type and node!in Cousin Cl Tail:Overfill;Nigh-Ler•el Sensor other(speeit}'equipment h'pe and model irk Conunents. Dispenser ID ---_----- -- ❑ Dispenser Containment Sensor(')- l— Dispenser ID sl,ear'Valves(')- ❑ Dispenser Containment SenSor(s). 13Shear Float(s)and Clraiu(s). ❑ Shear Valves('). ❑ Dispenser es(a)- _-- ❑ Dispenser Containment Floats)and Chain(')- Disp enSer ID ❑ Dispenser Contaitunent Sensor(s). D1SpenSCC ID Sensor!'). ❑ Shear Vaives(s)- ❑ Dispenser Coutaiument ❑ Dispenser Containment Float(s)and Charn(s)• ❑ Shear Valves(s). and Chai ('}. [3 Dispenser Containment FloatChain (0- Dispenser ID - Dispenser ID 13 Dispenser Containrent Sensor('). ❑ Shear Valves(s). Clraun{s . ❑ Dispenser Containment Sensor(')- ❑ Dispenser Containment Float(s)and ❑ Shear Valves(s) and dispenser at the facility' this form• Include information far every tank Manufacturers' ❑ Dispenser Containment Float(')and ChM s • in,accordance contains more tanks or dispensers,copy _ was ectedlservt cedIf the facility 'checklists)to'verif}`this�°dation is correct jify that the egtupr'nent identified m this d manufactur p enerating bnell reports,l hav°e C. Certification-I ce this certification is infot�atton(e-g a ui nient capable of g guidelines.Attached ec tti meat.For ally` q p 19 Alarm historY the laN'otit of monitoring 1 i ® system set-uP and a pion plan s1�o«ins silt k all that app1Y) Q3-1650 also attached a copY of the rep (check Signature: Louis Na V al License No.: _ Technician Name lint 06-05-{1315 {904)476-7443 Certification No.: ar,;,tdv Fn�irfltntnental Testing Phone No-: