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MONI10UNG SYSTEM CERTIFATION 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 Bldg.No.: Site Address: 1524 FRESNO AVENUE City: STOCKTON Zip: 95206 Facility Contact Person: MIKE ELIASON Contact Phor-e No.: (209)948-9412 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: 3/24/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: ❑ FORMTEXT DIESEL Tank ID: ®In-Tank Gauging Probe, Model: MAG ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model 420 ❑Annular Space or Vault Sensor. Model: ❑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/ FXIV ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: FLOAT - FLAPPER ❑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). 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(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 -2A Dispenser ID: 2-3A ®Dispenser Containment Sensor(s). Model: ®Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Hoat(s)and Chain(s). ❑Dispenser Containment Flou(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: 1 A ®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). *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, 1 have also attached a copy of the report; (check afl that apply): ® System set-up ® Alarm history report Technician Name(print): MIKE LAWRENCE Signature: Certification No.: A26642 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: 3/2412011 Page 1 of 4 UN-036— www.unidoes.org Rev.01/17/08