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OIL EQUIPMENT SERE • STATE LICENSE No.323417 CLASSIFICATION. A-RAZ.,C611140 Division of Keith A. Tallia, Inc. STATE ENVIRONMENTAL ASSESSOR No.01781 Telephone: (209)754-1809 Fax: (209)754-5726 Poet Office Box 950 750 Industrial Way SAN ANDREAS,CALIFORNIA 95249 MONITORING SYSTEM CERTIFICATION This fonn must he used to document testing :111d servicing of monitoring equipment. If more than One monitoring system control panel is installed at the fatality, a separate certification or report must be pretfared 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 fonn to the local agency regulating UST systems within 30 days of test (late. Instructions are printed on the back of this page. A. General Information FacilityName: Bob Cat Central -__ Bldg.No.: Site Address: 1113 Shaw Road City: Stockton .__ Zip: Facility Contact Person: Dori FranZia _ Contact Phone Na: ( 209. Make/Model of Monitoring System: INCON TS 100012 Date of Testing/Setvicing: _ 9/8 X00 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: T 1 Req. Gas Tank ID: T 2 Diesel 0 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: W Annular Space or Vault Sensor. Model: TSP-I1T.S CX Annular Space'or Vault Sensor. Model: TSP ETS W Piping SumpiTrench Sensor(s). Model: TSP-11T.S _ C;t Piping Sump/I'rench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model-CampCJMi 1 1 er 2l• Ck Electronic Line Leak Detector. Model lipc * W Tank Overfill/High-Level Sensor. Modcl:61 S(1 Dro Tube IX Tank Overfill/High-Level Sensor. Model O Dispenser Containment Sensor(s). Model: Cl Dispenser Containment Sensor(s). Model: _ M Shear Valve(s). *LS300 CX Shear Valve(s). Cl *LS300 Dispenser Containment Floar(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Other(specify ui ment type and model in Section E on Page 2). 0 Other(specify equipment t e and model in Section E on Page 2). Tank ID: Wactp Oil Tank ID: 0 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 52 Annular Space or Vault Sensor. Model:P Om ter* O Annular Space or Vault Sensor. Model: 0 Piping SumptTrench Sensor(s). Modci: *Mod 2-9-- 0 0 Piping Sump/Trench Senson s). Model: Cl Fit l Sump Sensor(s). Model: Type-_TX.—. ❑ Fill Sump Sensor(s). Model: _ 11 Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: _ 0 Electronic Line Leak Detector. Model: _ 0 Tank Overfill/High-Level Sensor. Model:VPnl Ra 1 1 ohjC 0 Tank Overfill/High-Level Sensor. Model: 0 Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensor(s). Model: 8 0 Shear Valvc(s). U Shear Valve(s). Cl Dispenser Containment Iloags)and Chain(s). 0 Dispenser Containment Floa1(s)and Cham(s). ❑ Other(specify equipment t e and model in Section E on Page 21, 0 Other(s ecifv equipment x and model in Section on Page 2). C- Certification - I certify that the equipment identified in (his 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 sholcing the layout of intiouoring equipment. For a ry equipment eipable of ocn eratin,� such reports. I ha%e also im:ichrd :1 rnp) of the (rd eck atf that apphy: 0 system s t-up report: ❑ Alarm It ssttory repot. 7-ectmician Name (print): James g Ileslceth- - - Cert./Lie. No.: 0(;6�--__-_ Signaune: Teshu g Com any Namc• ///"`"""" ' S p Oil _Equipment Service Phone No.: � 20 754-1 808