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MAR-14-2006 00:44 Se ce Station Systems 41111 9311 8888 P.04 Monitoring System Equipment certification For Use 13y A11 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 system within 30 days of test date. A. General Information Facility Name: Loves Country Store Bldg.No_: Site Address: 1553 Colony @ Jacktone Rd City:_Ripon, CA zip: 95366- Facility Contact Person: Ted Contact Phone No.: (208)599-0740 Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 2/21/06 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID Tank ID• ❑ In-Tank Gauging Probe. Model; 7 ❑ In-Tank Gauging Probe, Model: ❑ Annular Space or Vault Sensor, Model: 7 p Annular Space or Vault Sensor. Model; 7 0 Piping Sump\Trench Sensor(s). Model: 7 _ ❑ Piping Sump 1 Trench Sensor(s). Modcl: ? ❑ Fill Sump Sensor(s). Model; ? Q Fill Sump Sensor(s). Model: ? ❑ Mechanical Line Leak Detector. Model- 7 q Mechanical Line I.cak Detector. Model: 7 Q Electronic Line Leak Detector, Model: 7 [] Electronic Linc Leak Detector. Model: 7 Q Tank Overfill 1 High-Level Sensor. Model: 7 p Tank Overfill 1 High-Level Sensor. Model: 7 Q 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]Do Tank ED-- E3 In-Tank Gauging Probe. Model; 7 _ ❑ In-Tank Gauging Probe. Model: ? ❑ Annular Space or Vault Sensor, Model: ? ❑ Annular Space or vault Sensor. Model: 7 0 Piping Sump\'french Sensor(s). Model: 7 p Piping Sump 1 Trench Sensor(s). Model: ? ❑ Fill Sump Sensor(s). Model: ? ❑ Fill Sump Sensor(s). Model; ? ❑ Mechanical Line Leak Detector. Model: 9 ❑ Mechanical Line Leak Detector. Model; ? p Electronic Line Leak Detector, Model: 7 p Electronic Line leak Detector. Model: 7 El 'lank Overfill%High-Level Sensor. Model: ? p 'rank Overfill\High-Level Sensor. Model: 7 ❑ Other(specify equipment type and model in Scction E on Page 2). ❑ Othcr(specify equipment type and model in Section E on Page 2). Dispenser ID: 23Dispenser ID: 24- M Dispenser Containment Sensor(s). Model: YR 784380.208 29 Dispenser Containment Sensor(s). Model: VR 794380-208 99 Shear Valve(s). 99 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID; 25- Dispeoser ID: 26- $1 Dispenser Containment Sensor(s). Model: VR 7s4390,208 15 Dispenser Containment Sensor(s). Model: VR 794380-208 99 Shear Valve W. Qg Shcar Valve(s). n Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment bloat(s)and Chain(s). Dispenser ID: 27- Dispenser ID: a Dispenser Containment Sensor(s). Model; VR 704380.208 __ ❑ I)ispcnscr Containment Sensor(s). Model: 7 Ig Sltear 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 forth.Include information for every tank and dispenser at the facility C. Certification- f certify that the equipment identified in this document was inspectedtserviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'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; (check alt that apply): Q System set-up Q Alarm history report Technician Name(print): Matt Mulcahy Signature: 1116l� Mfg. Cert.#.: ICC# 5259466-UT License.No - 485184 Testing Company Name: Ser.Sta.Sys. Phone No.: 408 971-2"5 Site Address: 1553 Colony @ Jacktone Rd Date of Testing/Servicing: 2121106