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0 0 MONITORING SYSTEM CERTIFICATION For Use BP AU Jurisdictions Within the State o,f California Authority Cited.' Chapter 6.7, Neaith 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_repojL=t_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: RAPID SERVICE CENTER CARDLOCK Bld .No.: Site Address: 3550HWY99 City: srocKn Zi : 95215 Facili Contact Person: MIKE ELIASON Contact Phone No.: 209)9459412 Make/Model of Monitorial System: INCON TS 1000 Date of Testin Servicitl :1JULY 26,2007 B. Inventory of Equipment Tested/Certified Cheek the ippropiate hexes to Indicsite specific a ui meat tos ted/serviced: Tank ID:RE ULAR Tank ID: Z In-Tank Gauging Probe. Modct:MAG ❑ In-Tank Gauging Probe. Model:_ Z Annular Space or Vault Sensor. Model FLOAT ❑Annular Space or Vault Sensor. Model, Z Piping Sump/Trench Sensor(s). Model:FLOAT ❑Piping Sump/Trench Scnsor(s). Model: . ❑Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model:STP MLD ❑Mechanical Line Leak Detector. Model:_ ❑ Electronic Line Leak Detector. Model:_ ❑Electronic Line Leak Detector. Model:_ Z Tank Overfill/High-Level Sensor. Model:FLOAT ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment a 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 Smsor(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 I High-Level Sensor. Model:_ ❑Tank Overfill/High-Level Sensor. Model:_ Other(specify equipment type and model in Section E on Pae 2). ❑Other(specify equipment a and model in Section E on Page 2). Dispenser ID: 1-2 REGULAR Dispenser ID: ❑Dispenser Containment Sensor(s). Model_ ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑Shear Valve(s). Z Dispenser Containment Flogs and Chains . ❑Dispenser Containment Flo s and Chain(s). Dispenser ID;_ Dispenser ID: ❑Dispenser Containment Sensor(s). Model:_ ❑Dispenses Containment Season s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats and Chain (s). ❑Dispenser Containment Floats and Chain(s), Dispenser to:_ Dispenser ID:_ ❑Dispenser Containment Sensor(s)- Model• ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). *If the facility contains more ranks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification - 1 certify that the equipment identified in this document was inspceted/scrviccd in accordance with the manufacturers' guidelines. Attached to the 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 me report; (check all that apply): M System set-up Z Alarm history report Technician Name(print): ROBERT NE/MEYER Si ature: J-1 ~ Certification No:3 64 7353 760 License:803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: 0 446-6151 Address: 607 ELMIRA RD,PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: JULY 26,2007 Page 1 of 3 Monitoring System Certification