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MONITORING SYSTEM CERTIFIC XTION Jae By All Jurisdictions Within the State of Calitorn. Authority Cited:Chapter 6.7,40h and Safety Code;Chapter 16, Division 3 Title 23,�itomia 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 monitoring system control panel by the technician who performs the work. A copy of this forth must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulefing UST systems within 30 days of test date. A.General Information Facility Name: CIRCLE K 2701205,CO.123 (N-206) City: LATHROP CA Zip:95330 Site Address: 16470 CAMBRIDGE Contact Phone No: 858-4116 Date of Testing/Service: 06/30/2006 Facility Contact Person: MANAGER Make/Model of Monitoring System:TLS-350 Work Order Number: 2243625 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1-87 Tank ID: 2-91 In-Tank Gauging Probe. Model D In-Tank Gauging Probe. Model: 71 Annular Space or Vault Sensor. Model: 303 Annular Space or Vault Sensor. Model: 303 Piping Sump/Trench Sensor(s). Model: Piping Sumpfrrench 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). Omer(specify equipment type and model in Section E on page 2). TanklD: anklD: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench 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 OveRll/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 Dispenser ID: Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: 7 Shear Valve(s). Shear Valve(s) ElDispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensoria) Model: Dispenser Containment Sensor(s). Motley ❑ Shear Valve(s). Shear Velve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser lD: ❑ Dispenser Containment Sensors) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). ElDispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Cham(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 leg manufacturers'checklists)necessary to verify that this information is correct. and a Site Plan shoving 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❑Alamt history report Technician Name(print): DOUGLAS HARTY Signature: Certification No.: 006-05-0253 License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 06/30/2006 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification