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MONITORING SYSTEM CERTIFICATION For By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Hear,,,id Safety Code;Chapter 16, Division 3 Title 23,Callf&,,wCode 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 monhorinc system control oanel 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: 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: 11114/2008 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 71 In-Tank Gauging Probe. Model: MAG ZI In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 303 Annular Space or Vault Sensor. Model: 303 X Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensoria). Model: 208 Fill Sump Senors). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: MLDFX1 V X Mechanical Line Leak Detector. Model: Electronic Line Leek 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 10: 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 Sumprrrench Sensor(s). Model: Piping Sumprrrench Sensor(s). Model: Fill Sump Sensor(s). Model: FIII 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 modal in Section E on page 2). Otherec's ( p dY equipment type and modal in Section E on page 2). Dispenser Dispenser 10: 3/4 Dispenser Containment Sensors) Model: Dispenser Containment Sensogs) Model: X Shear Valve(s). X ShearValve(s) IKDispenser Containment Float(s)and Chain(s). X Dispenser Containment Floal(s)and Chaln(s). Dispenser ID: Dispenser ID: Dispenser Containment SensoKs) Model: Dispenser Containment SenspT(a). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Flost(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensors) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chablis), 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 cer6flcation 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 DESBIENS Signature: Certification No.: A22883 License. No.: 743160(Class'A'General Enginedng Contractor License) Testing Company Name:Tanknology Phone No.: (800)800-4633 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