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• PDDD DD • MONITSUNG SYSTEM CETIFI TIO For`se By All Jurisdictions Within the State of California v 2009 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Co e of regulations This form must be used to document testing and servicing of monitoring equipment. crate certification or r ,ENT H �T h monitoring system control panel by the technician who performs the work. A copy of this form must be p tem 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: Gas Depot Bldg.No.: Site Address: Cold Start Monitor Certification. City: Manteca Zip: 95336 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 10/29/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates cific equipment ins cted/serviced: Tank ID: Premium Tank ID: Regular ❑fn-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: 19 Annular Space or Vault Sensor. Model: 322 ®Annular Space or Vault Sensor. Model: 322 ®Piping Sump/Trench Sensor(s). Model: Mag ®Piping Sump/Trench Sensor(s). Model: Mag 10 Fill Sump Sensor(s). Model: 208 ®Fill Sump Sensor(s). Model: 208 ®Mechanical Line Leak Detector. Model: LD-2000 ®Mechanical Line Leak Detector. Model: LD-2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/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 type and model in Section E on Page 2). Tank ID: Diesel Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: Mag ❑Piping Sump/Trench Sensor(s). Model: 11 Fill Sump Sensor(s). _ Model: 208 ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: LD-2000 ❑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(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID: 314 ®Dispenser Containment Sensor(s). Model: 352 ®Dispenser Containment Sensor(s). Model: 352 ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ®Dispenser Containment Sensor(s). Model: 352 0 Dispenser Containment Sensor(s). Model: 352 ❑Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 ®Dispenser Containment Sensor(s). Model: 352 ®Dispenser Containment Sensor(s). Model: 352 ❑Shear Valve(s). ❑Shear Valve(s). J_g_2ispenser Containment Float(s)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. 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 Pian 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): �, stem et p Alarm history report Technician Name Gavin Williams Signature: A Certification No.: 6018864-UT License.No.: 856771 Testing Company Name: HMC- Henderson Maintenance Company Phone No.:(209) 467-7573 Site Address: Date of Testing/Servicing: 10/29/2009 Page 1 of 3