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11/05/2009 THU 8: 47 FAX 9163861256 A Teichert & Son Inc RWjr_jpfl::30 0001/0041410/28/2009 14:28 66139 3 CHUCK HILL PAGE 01/04 V 0 5 2009 MONITORING SYSTEM CERTEROODWEUMEALTH For Use By All Jurisdictions Within the State of CalRVICES �?uthority Cited Chapter 6.7, Health and Safety Code;Chapter 16,Division 3, 77tre 3, alffornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate cediflcatio or re o ust be M oared for each Monitor i g system eptltrol_ILaneI by the technician Who perforins the work, A copy of this form must be provided to the tank system owtiet/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 Nm-se: Teic er Bldg,No.: Site Address: 120- drank_W__.st C.i lire City. 5tocktorlZIP' Qk— Facility Contact Person:._..,Steve SChau do Contact Phone No.: 916-386:- Make/Model of Monitoring System: VR TLS 350 Date of Testing/Servicing:_f}9 25 00� B. Inventory of Equipment Tested/Certified Check the:appropriate boxes to Indicates specific a ui ment ins ect / rviced: Tank iD: # 1 Dies_ Tank ID: IM In-Tank Gauging Probe. Model: MAG- 0 In-Tank Gauging Probe. Model: G-1 0 Annular Space or Vault Scnsor. Model: 7 3 0� 0 Annular Space or Vault Sensor. Model: 794_4 38g_-4_Q7 til Piping Sump/Trench Scnsor(s). Model: 794$80=?Q$ IM Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ gill Sump Sensor(s). Model: ❑ Fill Sump Scnsor(s). Model. O Meebanical Line Leak Detector. Model: Q Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:_ 84848Q- 00 1"_ I ❑ Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor.. Model: 7900 5^001 M Tank Overfill/High-Level Sensor. Model:790095-001 , ❑ Other(specify equi2mont!.Xpe and model in Section E on Pae 2). ❑ Others eci equipment t e and model in Section E on Page 2). Tank lD: # Z Unit; Tank TD- M In-Tank Gauging Probe. Model:„ MAG-1 ® In-Tank Gauging Probe, Model: 0 Annular Space or.Vault Sensor. Model:_—Zg4.;AQ:.4.Q2— C3 Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s), Model: 79 0-208 G'1 Piping Sump/Trench Sensor(s). Model: ❑ bill Sump Sensor(s), Model: 0 rill Sump Sensor(s), Model: ❑ Mechanical Tine Leak Detector. Model: ❑ Mechanical Line Look Detector. Model: (8i Electronic Line Leak Detector, Model: 848480-001._ C1 Electronic Line Leak Detector. Model: ®'rank OverCll/Nigh-Level Sensor. Model!7-,4Q095^001 13 Tank Overflt/High-Level Sensor. Model: ❑ Other Ls2eoja Egui2mont!X2e and model in Section E on Pae . M Other coif ui mcnt't e and model in Section l;on Page 2. Dispenser ID:- 1/_Z Dispenser ID: IN Dispenser Containment Sensor(s). Model: 794380-ZQQ ..._ 0 Dispenser Containment Sensor(s). Model: ❑ Shear Valve($), 0 Shear Valve(s). ❑ DiEEonsor Containment Floats and Chains. 1 ❑ Dis cnser Containment gloats and Chaln s , Dispenser ID: 3/4 Dispenser ID: i@ Dispenser Containment Sensor(s). Model: 794380.2p3_ f3 Dispenser Containment Sensor(s). Model' ❑ Shear Valve(s). 0 Shear Valve($)• ❑ Dis cnscr Containment Float(,q and Chain(s- C1 Dis enscr Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Scnsor(s). Model: ❑ Dispenser Containment Scnsor(s), Model: M Sbear Valvc(s), ❑ Shear Valve(s). ❑ Dis eraser Containment Floa s and Chains. © bis cmor Containment Floats and Chains. "If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility, C. Cel-tilicaition - 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 Illstory report Technician Name(print): Keith Huston_____ Signature: Cortificatiou No.: AR 5 License.No-880430 Testing Company Name: EPICCo Ilance SKs_temS_____�Lt_C_ Pbone No.: 888-700-EPIC Testing Company Address: 0_0_1 Ba 11 D_r�„ ttl1.a 150 Date of Testitsg/Scrvicin);: 09/25-12009 t)N f136-1/4 Mage 1 of 4 Rev.oe;mamt www.unidneo.org