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MONITORING SYSTEM CERTIFICA TION • Ft 9 By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,HOhWand Safety Code;Chapter 16,Division 3 Title 23,CAM01-nia 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 monitonno 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 regulating UST systems within 30 days of test date. A.General Information Facility Name: YRC 813 City: TRACY CA Zip:95304 Site Address: 1535 E PESCADERO AVE Contact Phone No: 993-7946 Date of Tesling/Servioe: 04/13/2010 Facility Contact Person: CHRIS ROY Make/Model of Monitoring Syslem:TLS 350 Work Order Number: 2273688 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: T-1 WASTE Tank ID: T-2 WASTE X In-Tank Gauging Probe. Model: MAG 71 In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 303 Annular Space or Vault Sensor. Model: 303 X Piping Sump/Trench Sensor(s). Model: 205 Piping Sumpfrmnch Sensor(s). Model: 205 Fill Sump Sensods). 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). Other(specify equipment type and model in Section E on page 2). Tank ID: Tank ID: 1-4 IJI=AK OIL 71 In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 303 Annular Space or Vault Sensor. Model: 407 xi Piping Sump/Trench Sensor(s). Model: 205 X Piping Sumprrmnch Sensor(s). Model: 205 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 OveKll/High-Level Sensor. Model: FLAPPER Tank Overfill/High-Level Sensor. Model: FLAPPER Other(specify equipment type and model in Section E on page 2). Others ( petty equipment type and model in Section E on page 2). Dispenser Dispenser ID: ❑Dispenser Containment Sensor(s) 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). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s) Model: 7 Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). D Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensods). 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 forth. 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(e.g manufacturerschecklists)necessary to verify that this information is correct. and a Site Plan showing 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): rX System set-up X❑Alarm history report Technician Name(print): STEVEN WILLEMS Signature: hlr/v', Certification No.: B36743 License.No.: 743160(Class'A'Geneml Engmenng Contractor License) Testing Company Name:Tanknology Phone No.: (800)600-4633 Site Address: 11000 N.MoPac Expressway,suite 500,Austin,TX 78759 Date of Testing/Servicing: 04/13/2010 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08