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Moni,��,r�i�o7t3�tflitfftrteSlitleDf�t�a_^ Llon Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Cade of Regulations [oared for each monitoring system control panel by the technician who pe4roms the work. A copy of this form must be provided 1 ie tank system Owner / Operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems rithin 30 days of test date. A. General Information acility Name: Yellow Transportation TCY Bldg: SET Job#: T4 035427 ite Address: 1535 E. Pescadero Ave. City / State Tracy CA Zip: 95376 acility Contact Person: Richard Smith Contact Phone No.: 209-933-1573 lake / Model of Monitoring System: Veeder-Root TLS -250 B. Inventory of Equipment Tested or Certified Check the appropriate boxes to indicate equipment inspected or serviced; Date of Testing / Servicing. 6/29/2006 Tank ID Piping sump Tank ❑ ID In Tank Gauging Probe ❑ In Tank Gauging Probe ❑ Annular Space or Vault Sensor ❑ Annular Space or Vault Sensor ® Piping Sump / Trench Sensor9s) 205 ❑ Piping Sump / Trench Sensor9s) ❑ 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 / I-ligb-Level Sensor ❑ Other (specify equipment type and model in Comments. ❑ Other (specify equipment type and model in Comments. Tank ID Tank ID ❑ In Tank Gauging Probe ❑ In Tank Gauging Probe ❑ Annular Space or Vault Sensor ❑ Annular Space or Vault Sensor ❑ Piping Sump / Trench Sensor9s) ❑ Piping Sump / Trench Sensor9s) ❑ 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 Floats) 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). 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 ranks or dispenses, 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) O System set-up ® Alarm history Technician Name (print): Robert Soto Signature: Certification No.: 006-05-0131 Licnese No.: Testing Company Name: Shirley Environmental Corporation Phone No.: (909) 476-7443 Testing Company Address: 9595 Lucas Ranch Road, Rancho Cucamonga, CA Date of Testing / Service: 6/28/2006