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MONITNG SYSTEM CERTIFIC' r'ION F By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Hea n and Safety Code; Chapter 16, Division 3 Title 23, Calrromia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, 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 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 Date of Testing/Service: 11/13/2007 Facility Contact Person: MGR - DAVID COOPER Make/Model of Monitoring System:VR-TLS350 Work Order Number: 2252487 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95210 Tank ID: T1 -REG Tank ID: T2 -PRE X In -Tank Gauging Probe. Model: MAG PLUS %< In -Tank Gauging Probe. Model: MAG PLUS X Annular Space or Vault Sensor. Model: 303 X Annular Space or Vault Sensor. Model: 303 X Piping Sump/Trench Sensor(s). Model: 208/304 X1Piping Sump/Trench Sensor(s). Model: 208/304 X Fill Sump Sensor(s). Model: 208/304 Fill Sump Sensor(s). Model: 208/304 X Mechanical Line Leak Detector. Model: MLD X Mechanical Line Leak Detector. Model: LD2000 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: EXT. ALARM Tank Overfill/High-Level Sensor. Model: EXT. ALARM 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: Tank ID: 71 In -Tank Gauging Probe. Model: MAG PLUS El In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 303 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 208/304 Piping Sumprrrench Sensor(s). Model: X Fill Sump Sensor(s). Model: 208/304 Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: MLD Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: EXT. ALARM 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 : 1/2 Dispenser ID: 3/4 X❑ Dispenser Containment Sensor(s) Model: 208/304 X Dispenser Containment Sensor(s) Model: 208/304 X❑ Shear Valve(s). FX -1 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 X❑ Dispenser Containment Sensor(s) Model: 208/304 1XIDispenser Containment Sensor(s). Model: 208/304 XM Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 XO Dispenser Containment Sensor(s) Model: 208/304 X Dispenser Containment Sensor(s). Model: 208/304 ❑X Shear Valve(s). FX Shear Valve(s). DDispenser 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 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): ❑ System set-upX❑ Alarm history report Technician Name (print): KELVIN CRUZ Certification No.: A22519 Signature: _ License. No.: Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 11/13/2007 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01