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MONITAING SYSTEM CERTACATION 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 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: COUNTRY MARKET TB-Id . No.: Site Address: 1524 FRESNO AVENUE City: STOCKTON Zip: 95206 Facility Contact Person: MIKE ELIASON Contact Phone No.: (209)948-9412 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: JUN 30, 2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a !j ment inspected/service Tank ID:DIESEL Tank ID: Z In-Tank Gauging Probe. Model: MAG ❑ In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 420 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model:LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model:FLAPPER/FLOAT ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment e and model in Section E on Page 2). ❑ Other(specify equipment tye and model in Section E on Page 2). Tank ID: Tank ID: ❑In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑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: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(specifZ equipment e and model in Section E on Pae 2). ❑Other(specify e ui ment a and model in Section E on Pa e 2). Dispenser ID: 1A Dispenser ID: 1 -2A Z Dispenser Containment Sensor(s). Model: V/R STAND-ALONE Z Dispenser Containment Sensor(s). Model: V/R STAND-ALONE Z Shear Valve(s). Z Shear Valve(s). ❑Dis enser Containment Floats and Chains . ❑Dispenser Containment Floats and Chain (s). Dispenser ID:2-3A Dispenser ID:33=4 Z Dispenser Containment Sensor(s). Model: VVIR STAND-ALONE Z Dispenser Containment Sensor(s). Model: V/R STAND-ALONE Z Shear Valve(s). Z 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). ❑Dis enser 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): MIKE LAWRENCE Signature: Certification No:A26642 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: JUN 30, 2010 Page 1 of 3 Monitoring System Certification