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MONITWING SYSTEM CERTIFITION se By All Jurisdictions Within the State of Caiifom Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3 Title 23, ffornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility,a separate certification or report must be prepared for each monitorinQ, system control anal by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The ovmerloperalor 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: CIRCLE K#2705449,CO. 123 City: STOCKTON CA Zip:95207 Site Address: 7647 PACIFIC AVE Contact Phone No: 952-4515 Date of Testing/Service: 03/0912006 Facility Contact Person: MANAGER Make/Model of Monitoring System:VRTLS350 Work Order Number: 2241497 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1-91 Tank ID: 2-89 X In-Tank Gauging Probe. Model: MAG 1 X In-Tank Gauging Probe. Model: MAG 1 X Annular Space or Vault Sensor. Model: 794380-301 Annular Space or Vault Sensor. Model: 794380-301 X Piping Sumpfrrench Sensor(s). Model: 208 Piping Sumprrrench Sensors). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: MLD Mechanical Line Leak Deteclor, Model: LD2000 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: X in-Tank Gauging Probe. Model: MAG 1 In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 794380-301 Annular Space or Vault Sensor. Model: X Piping Sumpfrrench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector, Model: LD2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank OverfilliHigh-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). ispenser : 112 Dispenser ID: 314 MDispenser Containment Sensor(s) Model: 208 :X:l Dispenser Containment Sensor(s) Model-208 XQ Shear Valve(s). X Shear Valve(s) ❑Disponser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: RI Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s). Model: RI Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser lD: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: 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 form. Include information for every tank and dispenser at the facility. C. Certification I certify that the equipment identified in this document was inspectedlserviced 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 Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): System set-up Alarm history report r Technician Name(print): ROBERT SANTOS Signature: Certification No.: 5254122 License. No.: Testing Company Name:Tan knology Phone No.: (800)800-4633 Site Address: 8501 N. MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 03/09/2006 Page 1 of 3 Based on CA form dater. Monitoring System Certification