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MONIT&dNG SYSTEM CERTIOCATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. 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 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: SHANE&DA VES Bldg. No.: Site Address: 3550 HWY 99 City: STOCKTON I Zip: 95215 Facility Contact Person: MIKE EL/ASON Contact Phone No.: (209)948-9412 Make/Model of Monitoring System: INCON TS 1000 Date of Testing/Servicing: JUN 23, 2008 B. Inventory of Equipment Tested/Certified Check the apgropriate boxes to indicatespecific equipment inspected/serviced: Tank ID:87 Tank ID: E In-Tank Gauging Probe. Model:MAG ❑In-Tank Gauging Probe. Model:_ E Annular Space or Vault Sensor. Model:FLOAT ❑Annular Space or Vault Sensor. Model:_ E Piping Sump/Trench Sensor(s). Model:FLOAT ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model:_ ❑Fill Sump Sensor(s). Model:_ E Mechanical Line Leak Detector. Model:STP-MLD ❑Mechanical Line Leak Detector. Model:_ ❑Electronic Line Leak Detector. Model:_ ❑Electronic Line Leak Detector. Model:_ E Tank Overfill/High-Level Sensor. Model:FLOAT ❑Tank Overfill/High-Level Sensor. Model:_ ❑Other(specify equipment a and model in Section E on Pae 2). ❑Other(specify equipment a and model in Section E on Pae 2). Tank ID:RED DIESEL TanklD: E In-Tank Gauging Probe. Model:MAG ❑In-Tank Gauging Probe. Model:_ E Annular Space or Vault Sensor. Model:FLOAT ❑Annular Space or Vault Sensor. Model:_ E Piping Sump/Trench Sensor(s). Model:FLOAT ❑Piping Sump/Trench Sensor(s). Model:_ ❑Fill Sump Sensor(s). Model:_ ❑Fill Sump Sensor(s). Model:_ E Mechanical Line Leak Detector. Model: LD 2000 ❑Mechanical Line Leak Detector. Model:_ ❑Electronic Line Leak Detector. Model:_ E]Electronic Line Leak Detector. Model:_ E Tank Overfill/High-Level Sensor. Model:FLOAT E]Tank Overfill/High-Level Sensor. Model:_ E]Others eci equipment a and model in Section E on Pae 2). ❑Other(specify equipment a and model in Section E on Pae 2). Dispenser ID: 1_2 Dispenser ID:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Dispenser Containment Sensor(s). Model: E Shear Valve(s). ❑Shear Valve(s). E Dispenser Containment Floats and Chains . ❑Dispenser Containment Floats and Chain(s). Dispenser ID:_ Dispenser ID:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dis enser Containment Float(s)and Chains . ❑Dis enser Containment Floats and Chain (s). Dispenser ID:_ Dispenser ID:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats and Chain (s). ❑Dispenser Containment Floats 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 the Certification is information(e.g. manufacturers' checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): Z System set-up ® Alarm history report Technician Name rint): ROBERT NE/MEYER Signature: z�� Certification No: 3 64 7353 760 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707)446-6151 Address: 607 ELMIRA RD,PMB 336, VACAVILLE, CA 95687 Date of Testin Servicing: I JUN 23,2008 Page 1 of 3 Monitoring System Certification