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MONIICNG SYSTEM CERTIFATION For Use By All Jurisdictions Within the State of California Authority Cited.' Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form in ist be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each moliftoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ownr/operator. The owner/operaMCE�' rnthis form to the local agency regulating UST systems within 30 days of test ate. vv ��CC �U A. General Information Facility Name:Systems Transport 'I ''i 2009 Bldg.No.: Shop Site Address: 707 E.Roth Road ,l\, T .+F City: French Camp Zip 95231 Facility Co act Person: Steve Tucker ENVIi'`.; '1t1=") -ACTH Contact Phone No.: (209)983-8062 Make/Mode of Monitoring System:Veeder-II°i�t 1 TLIL -'2lS 'SLS Date of Testing/Servicing: May 19,2009 B. Inveni ory of Equipment Tested/Certified Check the a o riate boxes to indicatespecific a ui ment inspected/serviced:. Tank ID: #I DIESEL Tank ID: In-Tank aging Probe. Model: ❑ In-Tank Gauging Probe. Model: (x)Annular S ace or Vault Sensor. Model: 794390-407 ❑ Annular Space or Vault Sensor. Model: ( )Piping Su p/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill SumpSensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: (x)Mechanic Line Leak Detector. Model: VMI LD-2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Ovej fill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ other(spe My equipment tye and model in Section E on Pae 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: #1 Tank ID: ( )In-Tank Guging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular S ace or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Su up/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill SumpSensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanic I Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Ove fill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Dispenser I SATELLITE #1 Dispenser ID: (x)Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: ©Shear Val(e(s). ❑ Shear Valve(s). ( )Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser : MAIN DISPENSER #1 &2 Dispenser ID: ©Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: ©Shear Val ie(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser : SATELLITE #2 Dispenser ID: MI Dispenser Containment Sensor(s), Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: ©Shear Val!e(s). ❑ Shear Valve(s). ❑Dis enser ontainment Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). "If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility Q 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): ( )System set-up ( )Alarm history report Technician Name(print): Mike Jones Signature: Mike Jones Certification No.: ICC 5257977-UT License No.: 309105 Testing Co ipany Name:STOCKTON SERVICE STATION EQUIPMENT CO. INC. Phone No 209-464-8333 Site Addre 707 E.Roth Road,French Camp,CA Date of Testing/Seryicing: May 19,2009 Page 1 of 4 03/01