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MONITC "ING SYSTEM CERTIFIC TION F ;e By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3 Title 23, Camomia Code of Regulations This form mus=e d to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, a separate certification ormust 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 Facility Name: QUICK STUFF #7789 Site Address: 10858 TRINITY PKWY City: STOCKTON Contact Phone No: 952-2213 @ 8 MILE WEST OF HWY 5 Date of Testing/Service: 06/24/2009 Facility Contact Person: MGR - DAVID COOPER Make/Model of Monitoring System: TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Work Order Number: 2267343 CA Zip: 95210 Tank ID: 87 Tank ID: 91 In -Tank Gauging Probe. Model: MAG ❑X In -Tank Gauging Probe. Model: MAG Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 208 SMART SENSORS © Piping Sumprrrench Sensor(s). Model: 208 SMART SENSORS 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: 0 Tank Overfill/High-Level Sensor. Model: Other (specify equipment type and model in Section E on page 2). 11 Other (specify equipment type and model in Section E on page 2). Tank ID: LISIL Tank ID: 71 In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 208 SMART SENSORS ❑ 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 page 2). ❑ Other (specify equipment type and model in Section E on page 2). Dispenser Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valve(s). ❑ Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). 10 Dispenser Containment Float(s) and Chain(s). C 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 Site 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): -X System set-up X❑ Alarm history report Technician Name (print): KRISTOPHER BELL Signature: Certification No.: B33709 License. No.: 743160 (Class 'A' General Enginering Contractor License) Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 06/24/2009 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01