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MONITORING SYSTEM CERTIFICATION Fo -e By A[?,Jurisdictions Within the State ofCal%wda Authority Cited.-Chapter 6.7, He and S,t 'ty 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: Tracy Petro _ Bldg.No.: Site Address: 3400N.Mac Arthur City: Tracy Zip: 95376 Facility Contact Person: Karam Contact Phone No.: (209) 834-1220 Make/Model of Monitoring System: Veeder Root TLS350 Date of Testing/Servicing: 1/2/2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment tment inspected/serviced: Tank ID: #1-12,000 Gallon 91 Tank ID: #2-20,000 Gallon 87 ®In-Tank Gauging Probe. Model: 847390-109 ®In-Tank Gauging Probe. Model: 847390-109 ®Annular Space or Vault Sensor. Model: 794380-402 ®Annular Space or Vault Sensor. Model: 794380.402 ®Piping Sump/Trench Seasons). Model: 0794380.208 _ ®Piping Sump/Trench Sensor(s). Model: 0794380-208 ®Fill Sump Sensor(s). Model 0794380-208 ®Fill Sump Sensor(s). Model: 0794380-208 ®Mechanical Line Leak Detector. Model: VMI LD 2000 ®Mechanical Line Leak Detector. Model: VMI LD 2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-level Sensor. Model: Hall Float ®Tank Overfill/High-Level Sensor. Model: Ball Float ❑Other(specify equipment type and model in Section L on Pagi 2). ❑Other(specify equipment type and model in Section E on Page 2). i Tank ID: #3-8,000 Gallon Diesel _ _ Tank ID: ®In-Tank Gauging Probe. Model: 847380-109 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794380-402 ❑Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 0794380-208 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: 0794380-208 _ ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: VMI LD 2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: Ball Float ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Pasc;2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: #1/2 Dispenser ID: 1113/4 ®Dispenser Containment Sensor(s). Model: 0794280.208 ®Dispenser Containment Sensor(s). Model: 0794380-208 ®.Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: #5/6 Dispenser ID: 1117/8 ®Dispenser Containment Seasons). Model: 0794380-208 ®Dispenser Containment Sensor(s). Model: 0794380-208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Floaus)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: ,._ Dispenser ID: ❑Dispenser Containment Seasons), Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser 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 idetiified 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 moniPoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report;(check aft that apptr,: ® System set-up ® Alarm history report Technician Name(print): Gregory Hartman Signature:_ -4� Certification No.: A24823 _ License No.: 031640 Testing Company Name: Dialysis North Phone No.: (530) 229-1906 Site Address: Tracy Petro 3400 N.Mac Arthur T:_«:y,CA. 95376 Date of Testing/Servicing: 1/2/2008 Page 1 of 3