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MONITORING SYSTEM CERTIFICATION Fo r ly All Jurisdictions Within the State of California •Authority Cited:Chapter 6.7,HeAi.,raind Safety Code;Chapter 16,Division 3 Title 23, Cai.r/nia 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 certficabon or report must be prepared for each monitoring system control ca el by the technician who performs the work. A copy of this form must be provided to the tank system ownedoperetor. 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: CIRCLE K 2701205,MKT#2616 (N-206) City: LATHROP CA Zip:95330 Site Address: 16470 CAMBRIDGE Contact Phone No: 858-4116 Date of Testing/Service: 11/14/2008 Facility Contact Person: MANAGER-ROBERT Make/Model of Monitoring System:TLS350 Work Order Number: 2261321 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: REG Tank ID: PREM X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 303 Annular Space or Vault Sensor. Model: 303 71 Piping Sump/rrench Sensor(s). Model: 208 Piping Sump/rrench Sensor(s). Model: 206 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: MLD X Mechanical Line Leak Detector. Model: FX1 V 71 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). TanklD: TanklD: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model, Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sumpfrrench Sensor(s). Model: Piping Sum p/rrench Sensor(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/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: 3/4 Dispenser Containment Sensors) Model: Dispenser Containment Sensor(s) Model: X❑Shear Valve(s). X Shear Valve(s) EX Dispenser Containment Float(s)and Chain($). X Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensoria) 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Senwr(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 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 Alarm history report Technician Name(print): RHOME DESBI ENS Signature: * Certification No.: A22883 License.No.: 743160(Class'A'General Enginering Contractor License) Testing Company Name:Tanknology Phone No.: (800)8OD-4633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 11/14/2008 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01