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MONIAYNG SYSTEM CERTIFTWION M For Use BY All Jurisdiction Within the 3 California California Code of Regulations A'uthc fry Cited` Chaprdr G.7, hlealth and Safety Code; Chapter 16,hin This form m stbc Used to doctimenttesting acid servicing of monitoring equipme, -" °urate certification or_roport musC be tenpared fdr each mon tori, nasVstem eoiitrol panel by the technician who perforans the work. A copy of this form mast be provided to the tank the local agency regulating UST systems within 30 systeowns /operator. The owner/operator must submit a copy of this form to m days of test d te. A. GeDcr I ItOortli tfioD Bldg. No.: Shop Facility Nain :Sy5tem9Trdnsport City: French Camp Zip 95231 Site Address 707 P.ltoth Road Contact Phone No.: (209)9838062 Facility Colt ct persohi Steve Tucker Date of TesHn Servicing: May 19,2009 Make/Mode ofh4dditiiringSystem:Veeder-Root TLS�350 13. Iidven ory dt tquiptnent Tested/Certified Check then q rlati bats to radlCate s ifie c al meat ids cted/serviced: _ Tank ID: 'Yank TD: M DIESEL ❑ In-Tank Gauging Probe. Model: In-Tank d raging Probe:: Model: C3 Annular Space or Vault Scnsnr. Model: (I)Annular5 ace or Vadat Sensor Model 794390-407 O Piping Sump/Trench Sensor(s). Model: , ( }Piping Su p/Trench Sehsor(s). Model: C3 Fill Sump Sensar(s). Model: O Fill Sump Sensorial. Model: N/A color. Madel: 13 Mechanical Line Leak Det (x)Mechanie 1 Line Leak Detector. Model: VMI LD 2000 M Electronic Linc Leak Detector. Model: t] Electrons Line Leak Detector, Model: 0 Tank Overfill/High-Level Sensor. Model: Cl Tank Ov ill/High-Level Sensor. Model: p Other(specify equipment type and model in Section V on Page 2). ❑ Other ci ui ment a and model in Section E SLW 2 . Tank ID: Tank 10! ( )Tn•Tank auging Probe. Model: ❑ Tn-Tank Gauging Probe. Model: — Anoular pace or Valtlt Sensor. Model; ❑ Annular Space or Valet Sensor. Model: Piping Su' p/Tlandh Sensor(s). Madel:_ ❑ Piping Sump/Trench Sensor(s), Model: ❑ Fill Sum Se t' Model: M Pill Sump Sensor(s). Model: O Mecham' I Lint Look Detector. Model: ❑ Mechanicali,ine Lcak Detector, Model: CI Electroni Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: O Tank Ov Olt/Nigh-Level Sensor. Model: �^ O Tank Overfill/High-Level Sensor. Model: 4 Other s if 'Vi anent. a and model in SectionPage 2). Q Otho ui s ecif ment a and model in Section E on Page 2). Dispeftser 1 : SATF,LLITE 01 Dispenser iD: s Model: 794380-208 O Dispenser Containment Scnsor(s). Model: (R) hears e(s). itmdnt SensoY(.). ❑ $hear Valve(s). d Shear V ve(s}, Elo sand Chains . Dis case Codtainment Float s and Chains . 0 Disenscr Containment Dispenser f : MAIN DISPENSER 41 8r.2 Dispenser iD' ®Dispense Cahtainmdnt Sensor(s). Model: 794380.208 Cl Dispenser Containment Sertsor(s). Model: V V rssl Shear Va(s). ❑ Shear Valve(s). ti Dis ease a(s). dmdnt plo, send Chains. U Dispenser Containment Float(s)and Chain (s). Diopensor ID: SATELLITE 02 Dispenser iD: 0 Dispenserc Conlainmerit 5ensar(s). Model: 794380.208 C3 Dispenser Containment Sensor(s). Model: ®Shear VIve(s). E3 Shear Valve(s). GIDis ease Containment Flo $ and Chains . O Dis enscr 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. Certiflclition -i certify that the equipment identined in tbis document was inspected/serviced in accordance with the manufacturers' guidelines. Attlithed to this Certification is information (e.g. manufacturers' chockitsts) neecasary to verify that this information is If the layout of monitoring equipment For any equipment capable of generating such reports,I have Rise correct and h PId4 Plan showin attach a copy of the report;(cheek aft that apply): ( )System set-up ( )Alarm history report Signature: Xike Jones Techiticia' Naltie(print): Mike Jones g Certification No.: IVC 5257977-UT License No.: 309105 Testing C impiloy Name:STOCKTON SERVICE STATION EQUIPMENT CO. INC. Phone No 209-464-8333 Site Addr ss: 707 E.Roth Road$Fretich Camp,CA Date of Testing/Servicing: May 19,2009 Page 1 of 4 03101