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MONI*RING SYSTEM CERTIFOtTION For Use By All Jurisdictions Within the State of California Authority Cited.• Chapter 6.T,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. If more than one monitoring system control panel is installed at the facility,a A separate certification or m2p-r-t must be prepared for each mom!"nn 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. Instructions are printed on the back of this page. A. General Information Facility Name: CAARNG STOCKTON AASF Bldg.No.: Site Address: 2000 Stimson Rd. City: Stockton Zip: 96206 Facility Contact Person: MSG Pica Contact Phone No.: (2()9)981-_ 148 Make/Model of Monitoring System: EB W auto stik jr Date of Testing/Servicing: 1012312009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectediserviced Tank ID: I jp-8 15K UST Tank ID: 2 jpS 20k AST Z in-Tank Gauging Probe. Model: TSP LL2 in-Tank Gauging Probe. Model: TSP LL2 Annular Space or Vault Sensor. Model: TSP ULS Annular Space or Vault Sensor. Model: TSP ULS Piping Sump/Trench Sensor(s). Model: TSP ULS C]Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: C]Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: 171 Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: f❑-I Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: f-1 Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: 171 In-Tank Gauging Probe. Model: f❑-I In-Tank Gauging Probe. Model: n Annular Space or Vault Sensor. Model: n Annular Space or Vault Sensor. Model: r-1 Piping Sump/Trench Sensor(s). Model: ❑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: El Electronic Line Leak Detector. Model: f-1 Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: [ Other(specify equipment type and model in Section E on Page 2). R Other(specify equipment type and model in Section E on Page 2). Dispenser ID: REEL UDC Dispenser ID: TRANS SUMP 0 Dispenser Containment Sensor(s). Model: TSP ULS Dispenser Containment Sensor(s). Model: TSP ULS El Shear Valve(s). ❑Shear Valve(s). [I Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Flost(s)and Chain(s). Dispenser ID: Dispenser ID: F1 Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: C1 Shear Valve(s). ❑Shear Valve(s), ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: ❑Shear Vale(s). El Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). 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 Site Plot Plan showing the layout of monitoring equipment For any equipment ca able of generating such reports,I have also attached a copy of the report;(check all that apply): System set-u history report Technician Name(print): Hector Galindo Signature: Certification No.: 4246803760 License. No.: 512835 Testing Company Name: Tank Team inc, Phone No.:(805) 668-0067 Site Address: 2745 Sherwin Ave#8 Ventura C . 93003 Date of Tesfi*Servicing: 10/23/09