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Y y MONITORING SYSTEM CERTIFICATION 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 must be used to document testing and servicing of monitoring equipment.A separate certification or report must be pared 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 within 30 days of test date. A. General Information Facility Name: Quik Stop#132 Bldg.No.: Site Address: 3555 W. Hammer Ln. City: Stockton Zip: 95219 Facility Contact Person: Michael Karvelot Contact Phone No.: 510 657-8500 Make/Model of Monitoring System: Veeder- Root TLS 350 Date of Testing/Servicing: 06 /15 /2006 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui E ent inspected/serviced: Tank ID: Gasoline-87 Tank ID: Gasoline-89 ■ In-Tank Gauging Probe. Model: 0847390-109 0 In-Tank Gauging Probe. Model: 0847390-109 ■ Annular Space or Vault Sensor. Model: 0794390-409 ■ Annular Space or Vault Sensor. Model: 0794390-409 ■ Piping Sump/Trench Sensor(s). Model: 0794380-208 0 Piping Sump/Trench Sensor(s). Model: 0794380-248 ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model: FE Petro STP-MLD ■Mechanical Line Leak Detector. Model: FE Petro STP-MLD ❑ Electronic Line Leak Detector. Model: Cl Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(specity equipment a and model in Section E on P e 2). ❑Other(specify equipment a and model in Section E on P e 2 . Tank ID: Gasoline-91 Tank ID: ® In-Tank Gauging Probe. Model: 0847390-109 ❑ In-Tank Gauging Probe. Model: ■ Annular Space or Vault Sensor. Model: 0794390-409 ❑Annular Space or Vault Sensor. Model: ■ Piping Sump/Trench Sensor(s). Model: 0794380-208 ❑Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model: FE Petro STP-MLD ❑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(specifl equipment type and model in Section E on P e 2). ❑Other(s2ecify a ui ment a and model in Section E on P e 2). Dispenser ID: 1-2 Dispenser ID: 5-6 Dispenser Containment Sensor(s). Model: 0794380-208 Dispenser Containment Sensor(s). Model: 0794380-208 Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 Dispenser Containment Sensor(s). Model: 0794380-208 Dispenser Containment Sensor(s). Model: 0794380-208 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 Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chain(s). Lq2Lspertser 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 to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equip t capable enerating such reports,I have also attached a copy of the report;(check all that apply): ®System set-up ® m histor re ort Technician Name(print): Bruce Stewart Signature: L WA Certification No.: A31131 License.No.: 617238 Testing Company Name: Walton Engineering, Inc. Phone No.:( 916 ) 373-1152 Site Address: 3900 Commerce Drive,West Sacramento,CA 95691 Date of Testing/Servicing: 06 15 /2006 UN-036-1/4 Page 1 of 3 Rev.06/04/01 CUPA:San Joaquin County Env. Health ALTON INSPECTOR: Muniappa Naidu ENGtt INC. www.unidocs.org