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MONITb1tING SYSTEM CERTOI ICATION 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 7 -Signature: Facility Name: YELLOW FREIGHT Bld . No.: Site Address: 1535 E. PESCADERO AVE CI : TRACY I Zip: 95304 Facility Contact Person: SCOTT COVEY I Contact Phone NO.: 951) 522-5110 Make/Model of Monitoring System: VEEDER ROOT 350 I Date of Testing/Servicing: Nov 2o, 2oo7 B. Inventory of Equipment Tested/Cerffied Check the anoronriste boxes to indicate snecific eauinment inspected/ecrvired- Tank ID: MOTOR OIL 7 -Signature: Tank ID: WASTE OIL ® In -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Seasons). Model: _ ❑ Fill Sump Seasons). 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: FLOAT ® Tank Overfill / High -Level Sensor. _ Model: FLOAT ❑ Other (specify equipment = and model in Section E on P e 2). ❑ Other (specify equiLaent = and model in Section E on Page 2). Tank ID: 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 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 Overfill / High -Level Sensor. _ Model: ❑ Other (specify equipment type and model in Section E on Page 21. _ ❑ Other (specify equipment type and model in Section E on Page 2). 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 Float(s) and Chain(s). Dispenser ID: _ Dispenser ID: _ ❑ Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensors). Model ❑ Shear Valve(s). ❑ Shear Valve(s). _ Dispenser Containment Float(s) and Chain(s). ❑ Di ser Containment Flo2jW and Chain(s). Dispenser ID: _ Dispenser ID: _ ❑ Dispenser Containment Seasons). 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). 'If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certffleation - 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): ® System set-up ® Alarm history report Technician Name(print): MIKE LAWRENCE 7 -Signature: Certification No: A26642 I License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: 07) 446.6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: NOV 20, 2007 Page 2 of 4 Monitoring System Certification