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MONITRNG 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 monitorings system controlpanel 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 Facility Name: RAMOS OIL Bldg. No.: Site Address: 8925 W. T14ORNTON ROAD City: THORNTON I Zip: 95686 Facility Contact Person: DAVE NELSON Contact Phone No.: (916)371-3289 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: MAY 27, 2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecuic equipment inspected/serviced: Tank ID: 87 TankID:91 Z In-Tank Gauging Probe. Model:MAG Z In-Tank Gauging Probe. Model:MAG ❑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:_ Z Tank Overfill/High-Level Sensor. Model:MAG Z Tank Overfill/High-Level Sensor. Model:MAG ❑Other(specify equipment a and model in Section E on Pae 2). ❑Other(specify equipment a and model in Section E on Pae 2). Tank ID:RED DIESEL Tank ID:DIESEL ® In-Tank Gauging Probe. Model:MAG Z In-Tank Gauging Probe. Model:MAG ❑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:_ Z Tank Overfill/High-Level Sensor. Model:MAG Z Tank Overfill/High-Level Sensor. Model:MAG ❑Other(specify equipment a and model in Section Eon Pae 2 . ❑Other(specify equipment a and model in Section E on Pae 2). Dispenser ID: 1 -2.3.4 Dispenser ID:5=6. Z.Dispenser Containment Sensor(s). Model:208 Z Dispenser Containment Sensor(s). Model:208 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Floats and Chain(s). ❑Dispenser Containment Floats and Chain (s). Dispenser ID: 7A. 8.9A Dispenser ID: 9- 10A Z Dispenser Containment Sensor(s). Model:208 Z Dispenser Containment Sensor(s). Model:208 ®Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floats and Chain (s). ❑Dispenser Containment Floats and Chain(s). Dispenser ID: 10 Dispenser ID: VAPOR POD 8 TRANSITION SUMP Z Dispenser Containment Sensor(s). Model:_ Z Dispenser Containment Sensor(s). Model:208 Z Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats and Chain (s). 11 ❑Dispenser Containment Floats 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 the 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): Z System set-up Z Alarm history report Technician Name(print): RICHARD THOMAS Signature: �_s Certification No:834022 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707)446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: I MAY 27, 2010 Page I of 3 Monitoring System Certification