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• • 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 prepared 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 This is a certification of a new installation. Facility Name: Fremont Shell Site Address: 2494 E. Fremont St. City: Stockton Bldg. No.: Zip: 95205 Facility Contact Person: Michael Dominguez Contact Phone No.: 209 941-8743 Make/Model of Monitoring System: Veeder- Root TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/seryiced: Date of Testing/Servicing: 06 /23 /2005 Tank ID: Gasoline - 87 Tank ID: Gasoline -91 IN In -Tank Gauging Probe. Model: 0847390-109 ■ In -Tank Gauging Probe. Model: 0847390-109 8 Annular Space or Vault Sensor. Model: 0794380-302 ■ Annular Space or Vault Sensor. Model: 0794380-302 R Piping Sump / Trench Sensor(s). Model: 0794380-208 N Piping Sump / Trench Sensor(s). Model: 0794380-208 Fill Sump Sensor(s). Model: 0794380-208 0 Fill Sump Sensor(s). Model: 0794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ■ Electronic Line Leak Detector. Model: 848480-001 Electronic Line Leak Detector. Model: 848480-001 ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: E Other (specify equipment a and model in Section E on P e 2). ■ Other (specify equipment a and model in Section E on Page 2). Tank ID: 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: ❑ 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: ❑ 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 P e 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 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). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 E Dispenser Containment Sensor(s). Model: 0794380-208 Dispenser Containment Sensor(s). Model: 0794380-208 E Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 1 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser 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 Plan showing the layout of monitoring equipment. For any equipment capable of acoprating such reports, I have also attached a copy of the report; (check all that apply): 0 System set-up Q jTja0an histo rt Technician Name (print): Bruce Stewart Signature: Certification No.: 006-05-0810 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 / 23 / 2005 UN -036 - 1/4 Page I of 3 Rev. 06/04/01 CUPA: Environmental Health Department INSPECTOR: John J. Jackson WALTON .r. www.unidocs.org