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AST MONITORING SYSTEM CERTIFICATION This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be pr r fpr 2016 C each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the to e U owner/operator. A. General Information Facility Name: SANGUINETTI CIRCLE K Bldg.No.: Site Address: 4391 ESCALON BELLOTA RD City: FARMINGTON Zip: 95230 Facility Contact Person: Ron S Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 5/9/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 AST Tank Size: Tank ID: 91 AST Tank Size: ® In-Tank Gauging Probe. Model: MAG 9 N In-Tank Gauging Probe. Model: MAG 9 ® Annular Space or Vault Sensor. Model: 420 N Annular Space or Vault Sensor. Model: SHARED W/87 ® Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 ❑ 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 Page 2) ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: DIE AST Tank Size: Tank ID: E-85 AST Tank Size: N In-Tank Gauging Probe. Model: MAG 9 N In-Tank Gauging Probe. Model: MAG 12 N Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: SAHRED W/DIE N Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ 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 Page 2). ❑ Other(specify equipment type and model in Section E on Page 2), Dispenser ID: I/2 DispenserlD: 3/4 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 2 0 8 N Shear Valves) N 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 N Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 & 13/14 Dispenser ID: 11/12 - E-85 ONLY ®Dispenser Containment ® Dispenser Containment Sensor(s). Model:2 0 8 & 2 0 8 Sensor(s). Model: 2 0 8 • Shear Valve(s). N Shear Valve(s). ❑ Dispenser 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 generating such reports,I have also attached a copy of the report;(check all that applv): N System set-up N Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 95632 Date of Testing/Servicing: 5/9/2016 Monitoring System Certification Page 1 of 4 2/21/07