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Monitoring System Equipment Certification For Use RY All Jurisdictions tT�ithin The Slate of Cal,fornia 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 system within 30 days of test date. A. General Information Facility Name: Circle K Site Address: 1469 Hammer Ln. @ West City: Stockton, CA Bldg. No.: Zip: 95210 Facility Contact Person: Warren Contact Phone No.: (209) 478-1522 Make/Model of Monitoring System: WR TLS -350 B. Inventory of Equipment Teste&Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced: Date of Testing/Servicing: 6/25/04 Tank ED: 01 -Prem Tank ED: 02 -Flus c3 in - T Gauging Probe. Model: None ❑ In - TatGaugingProbe. Model: None 15 Annular Space or Vault Sensor. Model: VR 794390409 0 Annular Space or Vault Sensor. Model: VR 794390.409 ❑ Piping Sump \ Trench Sensor (s). Model: VR 7943x0.208 ❑ Piping Sump \ Trench Sensor (s). Model: VR 794380-209 ❑ Fill Sump Sensor(s). Model: None 0 Fill Sump Sonsor(s� Model: None 0 Mechanical Line Leak Detector. Model: Nona ❑ Mechanical Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: None 0 Electronic Line Leak Detector. Model: None 0 Tank Overfill \ High -Level Sensor. Model: Nona 0 Tank Overfill \ High -Level Sensor. Model: None ® Other ( specify equipment type and model in Section E on Page 2). 0 Other ( specify equipment type and model in Section E on Page 2). Tank ID• 03- egu Tank ID:las®1 0 In - Tank Gauging Probe. Model: Nom ❑ In - Tank Gauging Probe. Model: None 11 Annular Space or Vault Sensor. Model: VR 794390 109 0 Annular Space or Vault Sensor. Model: VR 794390.409 0 Piping Sump \ Trench Sensor (s). Model: VR 794389-208 0 Piping Sump \ Trench Sensor (s). Model: VR 794380-208 0 Fill Sump Sensor (s). Model: None ❑ Fill Sump Sensor (s). Model: None 0 Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: None 0 Electronic Line Usk Detector. Model: None ❑ Tank Overfill \ High -Level Sensor. Model: Nom 0 Tank Overfill \ High -Level Sensor. Model: None 0 Other( specify equipment type and model in Section E on Page 2). 0 Other( specify equipment type and model in Section E on Page 2). Dispenser ID: 01-02 Dispenser ID: 03-04 ❑ Dispenser Containment Sensor (s. el: None ❑ Dispenser Containment Sensor (s). Model: Nom 0 Shear Valve (s). 0 Shear Valve (s). 0 Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser ID: 05-09 Dispenser ID: 07-08 0 Dispenser ContainmentSensor (s. Model: None 0 Dispenser Containment Sensor s). Model: Nom ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser ID: 5910 Dispenser ID: 11-12 0 Dispenser Containment Sensor s). Mo None 0 Dispenser Containment Sensors . Model: None 0 Shear Valve (s} 0 Shear Valve (s). 0 Dispenser Containment Float (s) and Chain (a). 0 Dispenser Containment Float (a) 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 manufacturer's guidelines. Attached to this Certification is Information (e.g. manufactures' 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; ( check all that apply): 0 System set-up 0 Alarm history report Technician Name (print):SSS-Talbott Signature: Certification No.: 006-05-0844 License. No.: 485184 Testing Company Name: Ser. Sta. Sys. Site Address: 1469 Hammer Ln. @ West Phone No.: (408) 971-2445 Date of Testing/Servicing: 6125/04