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MONI*RING SYSTEM CERTIFWTION 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 monitorine 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 Facility Name: RAMOS OIL Bldg.No.: Site Address: 8925 W. THORNTON ROAD City: THORNTON 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: 3/29/2012 B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicates eciac equipment inspected/serviced: Tank ID: 87 Tank ID: 91 Z In-Tank Gauging Probe. Model: MAG Z In-Tank Gauging Probe. Model: MAG Z Annular Space or Vault Sensor. Model: 420 Z Annular Space or Vault Sensor. Model: 420 Z Piping Sump/Trench Sensor(s). Model: 208 Z Piping Sump/Trench Sewor(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: Z Tank Overfill/High-Level Sensor. Model: MAG Z Tank Overfill/High-Level Sensor. Model: MAG ❑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 TanklD: RED DIESEL Z in-Tank Gauging Probe. Model: MAG Z In-Tank Gauging Probe. Model: MAG Z Annular space or Vault Sensor. Model: 420 Z Annular Space or Vault Sensor. Model: 420 Z Piping Sump/Trench Sensor(s). Model: 208 Z Piping Sump/Trench Sensor(s). Madel: 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: MAG Z Tank Overfill/High-Level Sensor. Model: MAG Z Bh ❑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: 1/2 Dispenser ID: 3/4 Z Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7 ®Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser to: 7A Dispenser ID: 8 Z Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z 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 apply): Z System set-up Z Alarm history report Technician Name(print): RICHARD THOMAS Signature: R__ ,`41-5 Certification No.: B34022 License.No.: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No.: (707)446-6151 Testing Company Address: 607 ELMIRA ROAD,PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: 312912012 Page 1 of 4 UN-036— www.unidocs.org Rev.01/17/08