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MONITORING SYSTEM CERTIFICATION F is By All Jurisdictions Within the State of Califomia� Authority Cited.' Chapter 6.7, Hem and Safety Code; Chapter 16, Division 3 Title 23, CMomia 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 moort must be preoared for each monitodnQ system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ownedoperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test dale. A. General Information Facility Name: USA #110 Site Address: 2132 MARIPOSA ROAD Facility Contact Person: DEALER Make/Model of Monitoring System: V.R.TLS-350 B. Inventory of Equipment TestedlCertified Check the appropriate boxes to indicate specific equipment inspected/serviced City: STOCKTON CA Zip: 95205 Contact Phone No: 946-9282 Date of Testing/Service: 06/08/2006 Work Order Number: 2243114 Tank ID: 1-87 Tank ID: 2-89 71 In -Tank Gauging Probe. Model: MAG 71 In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: 420 71 Piping Sumprrrench Sensor(s). Model: 206 Piping Sump/Trench Sensor(s). Model: 206 X Fill Sump Sensor(s). Model' 208 ' Fill Sump Sensor(s). Model: 206 59 Mechanical Line Leak Detector. Model: FXIVFX1 Mechanical Line Leak Detector. Model: V Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overrill/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: _Xj In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe, Model: MAG X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: 420 X Piping Sumpfrrench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 X Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 X Mechanical Line Leak Detector. Model: FX1 V Mechanical Line Leak Detector. Model: FX1 DV 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). Dispenser : 1/2 Dispenser ID: 3 Dispenser Containment Sensor(s) Model: 208 — _X-1 Dispenser Containment Sensor(s) Model: 208 X� Shear Valve(s). X Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 4/5 Dispenser ID: 6/7 X❑ Dispenser Containment Sensor(s) Model: 208 Dispenser Containment Senors). Model: 208 X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11 )( Dispenser Containment Sensor(s) Model: 206X Dispenser Containment Sensor(s). Model:208 ❑X Shear Valve(s). X 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 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 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 X❑ Alarm history report Technician Name (print): JOEY MESA Certification No.: 00605-1532 Testing Company Name: Signature: % License. No.: Phone No.: (800) 800-4633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 06/08/2006 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01