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- MONITONG SYSTEM CERTIFIC ION For Up All Jurisdictions Within the State of Cali or it Authority Cited.- Chapter 6.7, Health and Safety Code; Chapter 16, Division 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. A 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 days of test date. MSIR Q �UtJ A. General Information „� Li1�iMEN"V HEALTH Facility Name: Stockton,CA Switch B J c5 Site Address: 3807 Coronado Ave City: Stockton CA Zip: 95204 Facility Contact Person: Ron Williams Contact Phone No.: 209-937_5840 Make/Model of Monitoring System: TLS-300 S.N#: 80587331703001 Date of Testing/Servicing: 11-20-2002 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: DIESEL-10,000 Tank ID: DIESEL-5,000 In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: ata ® Piping Sump/Trench Sensor(s). Model: ens ❑ Piping Sump/Trench Sensor(s). Model: ❑ 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/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(spccia equipment t e and model in Section E on Pae 2). ® Other(specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump 1 Trench Sensor(s). Model: ❑ Fill Sump Sen50r(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/High-Level Sensor. Model: ❑ Tank Overfill 1 High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). 1 ❑ Other(specify equipment t e and model in Section E on Page 2). 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). ❑ Disoenser 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valvc(s). ❑ Shear Valve(s). ❑Dis enser Containment'Float s)and Chain(s). ❑ Dispenser Containment Floats 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 inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information(e.g.manufacturers' checklists)necessary— verify that this information is correct and a Plot flan showing the layout of monitoring equipment. For any equipment capable of ge rating uch reports,I have also attached a copy of the report;(check all that apply): X System set-up ❑Alarm his report Technician Name(print): (KEITH ROWAN-MONITOR) Signature: Certification No.: 000-00-5266 License.No.: A HIC HAZ:W4027 Testing Company Name: Shirley Environmental Testing Phone No.: (626)444-7447 Site Address: 1928 Tyler Avenue Suite K South El Monte,CA 91733 Date of Testing/Servicing: 11-20-2002 Page 1 of 3 03/01 Monitoring System Certification