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Mar 25 03 08:37a Miles- Dotten 209-'--33-2650 p.l AlIftech 17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320; Fax: 209-533-2650 California Contractor 623541 A-Haz alltech@getrocket.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Get -n -Go Mart Date of Testing/Servicing: March 24, 2003 Facility Address: 574 Grant Line Road, Tracy CA Facility Contact Person: Satnam Singh Contact Phone No.: 833-3416 LIA: San Joaquin; Steven She Make/Model of Monitoring System: Veeder-Root TLS 350 B. Inventory of Equipment Tested/Certified: Check (he appropriate boxes to indicate snecifir Comments: C. Certification - 1 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 apply): ® System set-up ® Alarm history report Technician: 1" Mike Dotten Certification: Viceder-Root: 341-32-6743; Level 3. Page I of 3 03101 87 Regular Tank Tank ID: 91 Premium Tamk Fln-TankGauging Probe. Model: Mag 2 ar Space or Vault Sensor. Model: Wrap Around N In -Tank Gauging Probe. Model: Mag 2 E Annular Space or Vault Sensor. Model: Sump / Trench Sensor(s). Model: Float Sw. ❑ Fill Sump Sensor(s). Model: Wrap Around N Piping Sump / Trench Sensor(s). Model: Float Switch ® Mechanical Line Leak Detector. Model: FE Petro ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FE Petro ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: Drop Tube ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: Drop Tube ❑ Other ❑ Other Dispenser ID: 1&2 ® Sump: ®Dry ❑ Water []Product N Dispenser Containment Sensor(s). Model: Float Dispenser ID: 3&4 M Sump: ®Dry ❑Water ❑Product Switch ® Shear Valve(s) (Functional test) M Dispenser Containment Sensor(s). Model: Float Switch N Shear Valve(s) (Functional test) ❑ Dis enser Containment Float(s and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: S&6 R Sump: MDry []Water ❑ProduLt N Dispenser Containment Sensor(s). Model: Float Dispenser ID: 7&8 ® Sump: MDry ❑ Water ❑Product Switch N Shear Valve(s) (Functional test) ® Dispenser Containment Sensor(s). Model: Float Switch N Shear Valve(s) (Functional test) ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis nser Containment Floats and Chains . Dispenser ID: ❑ Sump: ❑Dry ❑ Water ❑Product ❑ Dispenser Containment Sensor(s). Model: Dispenser ID: ❑ Sump: ❑Dry ❑ Water []Product ❑ Shear Valve(s) (Functional test) ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s) (Functional test) ❑ Dispenser Containment F1oat s) and Chain(s). ❑ r%*------- Containment Float(s) and Chain(s). Comments: C. Certification - 1 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 apply): ® System set-up ® Alarm history report Technician: 1" Mike Dotten Certification: Viceder-Root: 341-32-6743; Level 3. Page I of 3 03101