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RlEceva MAY 2 5 2007 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California N- ��E'�� Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, Cali CTSCJ tfdns 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 ownedoperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: ESTES Trucking Bldg. No.: Site Address: 7611 S. Airport Way City: .Stockton Zip 95206 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: Veeder-Root TLS 350 Date of Testing/Servicing: May 04,2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui oment ins ected/serviced: _ Tank ID: kl DIESEL Tank ID: _ ln=lank Gauging Probe. Model: ❑ In"Tank Gouging Probe Model (x)Annular Space w Vault Sensor. Model:794380-302 ❑ Annular Space or Vault Sensor. Model is I Pining Sump/Trench Sensor(s). n4odel: 794380-20S - 13 Piping Sump/ rrerclsensor(s)_ Model J I ill Sump Sensor(s). Model: _ U Fill Sump Sensor(s). Model. (x)Mechanical Linc Leak Detector. Model:Fe Petro MILD-D O Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model:_ ❑ Electronic Line Leak Detector, Model: O Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑`Other s'ecfy e uipment e and model in Section F.on Pae 2 ❑ Other(specify equipment type and model in Section—Bon Page 2)_ Tank ID: 02 Tank Ill: OIn•lank 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 O Piping Sunup./Trench Sepsor(s). Model: ❑ Fill Sump Sensor(s). Model: __ ❑ Fill Sump Sensor(s). Model: Cl Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: _ O Electronic Line Leak Detector. Model:_ _ _ ' -0 Electronic line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor. Model: _ _ O Tank Overfill, High-Level Sensor. Model: ❑ Other(specify equipment ty e and model in Section E on Page 2). O Other 1 pe-ifi_ e u pment type and model in Section F,on Page 2). Dispenser ID: Dispenser ID. O Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Scmor(s). Model Shear Valve(s). j�l O Shear Vaisre(s)- ----— --- ( )Dispenser Containment Floats)and Chain(s). O Dispenser Con[alriment Float(s)and Chalets). . Dispenser ID: - _ Dispenser 1D: _ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ❑ Shear Valve(s). ®Dis ense(Containment Floats)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser In IwI Dispenser ID: I:) Dispenser Containment Sensor(s). Model: N C3Dispenser Containment Sensor(s). Model:_ JD']DispenYatve(s). p ❑ ShenrV Ivo(s 1. — upznser Containment Floa[(s)ssnd Ohain(s), �� O Dtep nsnr Conlninment Flo,t(s)and Cbaus(o) 'II 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 to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): (x)System set-op- - (x)Alarm history report Technician Name(print):. Eric Molgaard Signature.: Eric:MoCgaard Certification No.: ]CC 5250200-UT,Veeder-Root 27995 License No.: 309105 " Testing Company Name:STOCKTON SERVICE STATION EQUIPMENT CO. INC. Phone No 209-464-8333 Site Address: 7611 S. Airport Way,Stockton,CA 95206 Dace of i oseinJServicine: May 04,2007 Page 1 of 3 03101 Monitoring System Certification