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i RIMMED NG SYSTEM CERTIFI�TION For se 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 Reg 9 N 0 7 This form must be used to document testing and servicing of monitoring equipment. A separate certification or reoort mustFt4"Wtufutis ALTH monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank syst"E r MFVRWES 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, Inc Bldg.No.: Site Address: 3400 N. MacArthur City: Tracy Zip: 95376 Facility Contact Person: Karam Contact Phone No.: (209) 834-1220 Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 1122/2007 B. Inventory of Equipment Tested/Certified Check the RDDropriate boxes to indicates cific equipment ins ted/serviced: Tank ID: #1 -12,000 Gallon 91 Tank ID: #2 -20,000 Gallon 87 Z In-Tank Gauging Probe. Model: 847390-109 Z In-Tank Gauging Probe. Model: 847390-109 Z Annular Spam or Vault Sensor. Model 794380-402 Z Annular Space or Vault Sensor. Model: 794380-402 Z Piping Sump/Trench Sensor(s). Model: 0794380-208 Z Piping Sump/Trench Sensor(s). Model: 0794380-208 Z Fill Sump Sensor(s). Model: 0794380-208 Z Fill Sump Sensor(s). Model: 0794380-208 Z Mechanical Line Leak Detector. Model: VMI LD 2000 Z Mechanical Line Leak Detector. Model: VMI LD 2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: Ball Float Z Tank Overfill/High-Level Sensor. Model: Ball Float ❑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: #3 -8,000 Gallon Diesel Tank ID: Z In-Tank Gauging Probe. Model: 847380-109 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794380.402 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 0794380.208 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 0794380-208 ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: VMI LD 2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: Ball Float ❑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: #112 Dispenser ID: #314 Z Dispenser Containment Sensor(s). Model: 0794380-208 Z Dispenser Containment Sensor(s). Model: 0794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: #516 Dispenser ID: #7/8 Z Dispenser Containment Sensor(s). Model: 0794380-208 Z Dispenser Containment Sensor(s). Model: 0794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ElDispenser Containment Sensor(s). Model: E:1Dispenser Containment Sensor(s). Model: [IShear Valve(s). ElShear 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,I have also attached a copy of the report;(check all that applv): ® System set-up ® Alarm history yreport . Technician Name(print): Gregory Hartman Signature: �r +2t11 ti\ Certification No.: A29881 License.No.: 03-1640 Testing Company Name: Dialysis North Phone No.:(530) 229-1906 Site Address: 3400 N MacArthur Tracy CA 95376 Date of Testing/Servicing: 112212007 Page 1 of 3