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RECEIVED MONITORING SYSTEM CERTIFICATION JUL8 This form must be used to document testing and servicing of monitoring equipment. It more � � ' t the fasjl45 a -A separate certification or report must be prepared for each monitoring system control panel by the technician wharfonns the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copJU"1FRt4f"N eN$S UH regulating UST systems within 30 days of test date.—Instfuetions ar printed DEPARTMENT A. General Information Facility Name: Love's Site Address: 1553 Colony Rd. Facility Contact Person:. NEIL Make/Model of Monitoring System: TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment suspected/serviced:: Bldg. No.: City: Ripon Zip: 95366 _ Contact Phone No.: ( 209 ) 599-0740 Date of Testing/Servicing: 5129/14 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). 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 Linc 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 P on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: DISP 21 Dispenser ID: 23 24 X Dispenser Containment Sensor(s). Model: 794380-208 X Dispenser Containment Sensor(s). Model: 794380-208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: 2122 X Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Scusor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 2223 Dispenser ID: X Dispenser Containment Sensor(s). Model: 794380 208 ❑ 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 forrn. 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 -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 all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): RON WOOD Signature: ON FILE A32620 License. No.: 12559 a,b,c Testing Company Name: L.A.PERKS PLUMBING & HEATING INC. Phone No.: (77.r) 15 R-4403 Site Address: SAME AS ABOVE Date of Testing/Servicing: 5/29/14 Page 1 of 3