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MONITANG SYSTEM CERTIAATION For Use 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 Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be nrenared 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 Bldg. No.: Site Address: 3550 HWY99 City: STOCKTON I Zip: 95215 Facility Contact Person: MIKE EL/ASON Contact Phone No.: (209)468-3420 Make/Model of Monitoring System: INCON Date of Testing/Servicing: JUNE 27, 2006 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecifrc a ui ment inspected/serviced: Tank ID: REGULAR Tank ID: Z In-Tank Gauging Probe. Model: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 Sensor(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 a and model in Section E on Pae 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Tank ID:RED DIESEL Tank ID:_ Z In-Tank Gauging Probe. Model: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 Sensor(s). Model:_ ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model:_ Z Mechanical Line Leak Detector. Model:FXI ❑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 a and model in Section E on Pa e 2). ❑Other(specify equipment a and model in Section E on Page 2). Dispenser ID: 11-22 Dispenser ID: 5 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Floats and Chain(s). Z Dispenser Containment Floats and Chain (s). Dispenser ID:3-3A Dispenser ID:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑Shear Valve(s). Z Dispenser Containment Floats and Chain (s). ❑Dis enser Containment Floats and Chain(s). Dispenser ID:44A Dispenser ID:_ ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑Shear Valve(s). Z Dis enser Containment Floats and Chain(s). ❑Dispenser Containment Floats 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 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 the report; (check all that apply): ® System set-up ❑Alarm history report Technician Name(print); ROBERT NEIMEYER Signature; T Certification No: 06043717 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707)446-6151 Address: 607 ELMIRA RD,PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: I JUNE 27, 2006 Page I of 3 Monitoring System Certification