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Monies 5y,aa,5t=F%4WLration Authority Cited., Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This_form_Mustbaused_to_docummt_testing_and servicing o i t. _S_pe crate �ertiYlcations or reportsmustbr_ prepared for each monitoring system control panel by the the work. A copy of this form must be provided to the tank system Owner / Operator. The owner o s b copy of this form to the local agency regulating UST systems witbin 30 days of test date. AUG 1 5 2006 A. General Information acility Name: ite Address: acility Contact Person: lake / Model of Monitoring System: TCY 1535 E. Pescadero Ave. SET Job#: T4 035427 Tracy CA Zip: 95376 Richard Smith Contact Phone No.: 209-833-1573 Veeder-Root TLS -250 Date of Testing / Servicing 6/28/2006 B. Inventory of Equipment Tested or Certified Check the appropriate boxes to indicate equipment inspected or serviced; Tank ID Waste Oil 1,000 Tank ® ID Waste 0114,000 In Tank Gauging Probe 730 ® In Tank Gauging Probe 730 ® Annular Space or Vault Sensor 303 ® Annular Space or Vault Sensor 303 ® Piping Sump / Trench Sensors) 205 ® Piping Sump / Trench Sensors) 205 ❑ Fill Sump Sensor(s) ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill / High -Level Sensor ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment type and model in Comments. ❑ Other (specify equipment type and model in Comments. Tank ID Waste Oil 6,000 Tank ❑ ID Piping Sump In Tank Gauging Probe ® In Tank Gauging Probe 730 ® Annular Space or Vault Sensor 407 ❑ Annular Space or Vault Sensor ® Piping Sump / Trench Sensors) 205 ® Piping Sump / Trench Sensors) 205 ❑ Fill Sump Sensor(s) ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill/ High -Level Sensor ❑ Tank Overfill/ High -Level Sensor ❑ Other (specify equipment type and model in Comments. ❑ Other (specify equipment type and model in Comments. Dispenser ID Dispenser ID Dispenser Containment Sensor(s). ❑ Dispenser Containment Sensor(s). Shear Valves(s). ❑ Shear Valves(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID Dispenser ID ❑ Dispenser Containment Sensor(s). ❑ Dispenser Containment Sensor(s). ❑ Shear Valves(s). ❑ Shear Valves(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID Dispenser ID ❑ Dispenser Containment Sensor(s). ❑ Dispenser Containment Sensor(s). ❑ Shear Valves(s). ❑ Shear Valves(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 manufacturers' guidelines. Attached to this certification is information (e.g. manufacturers' checklists) to verify 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 Technician Name (print): Robert Soto Signature: Certification No.: 006-05-0.131 License No.: Phone No.: (909) 476-7443 acamonga, CA Date of Testing / Service: 6/28/2006 Testing Company Name: bt Testing Company Address: 9595 M