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MONITORING SYSTEM CERTIFIC A TION F se By All Jurisdictions Within the State of Callfom,a Authority Cited:Chapter 6.7, Hc�RI and Safety Code;Chapter 16,Division 3 Title 23, t mia 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 monitoring system control Panel by the technician who performs the work. A copy of this tone 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 Testing/Service: 03/24/2011 Facility Contact Person: KRIS/ROY Make/Model of Monitoring System:VR TLS 250 Work Order Number: 2280192 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: SOAP Tank ID: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 407 Annular Space or Vault Sensor. Model: X Piping Sumpffrench Sensor(s). Model: 205 Piping Sump/Trench Sensor(s). Model: Fill Sump Senors). 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). TanklD: TanklD: 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 Senscr(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 2). Other(specify equipment type and model in Section E on page 2). lspenser Dispenser ID: ❑Dispenser Containment Sensors) Model: Dispenser Containment Sensors) 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 Sensors) Model: Dispenser Containment Sensors). Model: ❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Roars)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensors) Model: Dispenser Containment Sensors). 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. Certification I certity that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines. Attached to this certification is information(e.g manufacturers'checklists)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,1 have also attached a copy of the(Check all that apply): �X System set-up X❑Alarm history report Technician Name(print): CHARLES FERRUCCI Signature: Certification No.: 837513 License.No.: 743160(Class'A'General Enginering Contractor License) Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 11000 N.MoPac Expressway,suite 500,Austin,TX 78759 Date of Testing/Servicing: 03/24/2011 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08