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11/24/2008 14: 06 20946549*RING HMC PAGE 01/04 ONI MSYSTEM CERTIFIVATION For Use Rv A11 Jurisdictions Within the State of Cafi/ornia Au�hority Cited: Chapter 6.7, Health and Safe4,Code; Chapter 16, Division 3, Title 23, California Code r?f Regulations This form must be used to document testing and servicing of monitoring equipment, A_separate certificationor report muat he prepared for cacti monitoring;tsv_etM..control panel by the technician who performs the work, n copy of this form must be provided to the tank system owner/operator. The owner6pera.lor must submit a copy orchis form to the local agencv regulating UST systems within 30 days of test date. A. General Information Facility Nume: Skymart Enterprizes LTD Bldg.No.: Site. Address: 713 N El Dorado City: Stockton Zip: 95202 Facility Contact Person: Mo Contact Phone No.: 209 939-1755 Make/Model of Monitoring Systcm: VR TLS 350 Date of Testing/Servicing: 11/19/2008 R. Inventory of.Equipment Tested/Certified �. �_. Check t�appropriate hexes to indicate specific equipment ins eetcd/ccrviced: RE,, Tank iD: i7 Tank ID: 91 ®hi-Tank Ouging Probe. Model: MAG-1 ®In-Tank Gauging Probe. Model: M -1 0 Annular Space or Vault Sensor. Model: 001 0 Annular Space or Vault Sc or, Model: 001 1Z Piping Sump/Trench Scnsor(s). Modcl; 208 ®Piping Sump/Trench Sensnr(s), Model: �� NTNL ®Fill Sump'Scnsor(s). Model: 208 - ®Fill Sump Sensor(s). Model: ow ❑Mechanical Line Leak Detector. Model, ❑Mechanical Line Leak Detector. MCM00: ®1'lectronic Linc Lcak Dctccror. Model; PLI-D ER IJlcctronic Line Leak Detector, [Model.. PLLD ❑ Tank nvei,ill/High-Level Scnsor, Model: ❑Tank Overfill/High-I,.cvcl Sensor. Model: ®Other(specify equipment type and rnndcl in Section r on Page 2), ❑Other(specify equipment type and model in Section F on Page 2). Tank ID: UISL Tank IM ®fn-Tank Quiging Probe. Model; MAG-1 ❑in-Tank Gauging Probe. Moder Annular SLace or Vault Scnsor. Modcl; 001 ❑annular Space or Vault Sensor. Model: ®Piping Surnp/Trench Sensor(s), Moder 208 El Piping Sump/Trench Saisor(s). Model, Z Fill Sump Scnior(s), Model: 208 ❑Fill Sump 5cnsor(s), Model: ❑Mechanico l Linc t_cak Detector. Madcl; ❑Mechanical Line Leak DctuctQr, Moder Electronic f ine Leak Detector, Model' PLLD ❑Glcctronic Linc Lcak Detector, Model: ❑Tnnk Overfill/14igh-l.,cvct Scnsor, Model: ❑Tank Overfill/High-Level Scnsor. Model: ❑01her(.apcc,ify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Scction E on Page 2), Dispenser ID- 1/2 Dispenser iD: 3/4 ® Dispenser?'ontainmcnt Sensor(s). ""del: 208 Z Dispenser Containment Scnsor(s). MOdci: 208 Shcar ValvC(s)• M Shear Valvc(s). ❑Dispenser, ontainmcnt,Floats)and Chsin(s), ❑Dispenser Containment Float(s)and Chain(9), Dispenser If?: 5/6 - Dispenser iD, 7/8 ®Dispenser "otnainrncnt.Scnsor(s). Model: 208 ®Dispenser Containment Scor(s), Model: 208 ®Shcar Valve(-,), ®Shear Valvc(s). ❑Dicpcnscr r'.'ontainment Float(-,)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). 11 Dispenser til: 9/10 Dispenser iD: 11112 Dispenser a-ontainmcrx Scrnsor(s). Model: 208 ®Dispenser Containment Scnsor(s). Model; 208 ®Shcar Valv?!(s). 0 Shear Vatvc(s). ❑Dispenser t,::ontainmcnt Float(s)and Choin(s). ❑ Dispenser Containment Float(s)and Chain(s), *]f the facilit;;contains more tanks or dispensers,copy this form. Include information for evcry tank and dispenser at the facility. 1. C. Certileation -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. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plnn 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 than apply): El System set-up ❑ Alsirm T.' .ory report Technician Name(print): Heath A McEver Signature: Corti icatior No.: A27562 License.N .: 5236756-UT Testing Company Name: SST-Service Station Testing Phonc No.: (209) 465-5577 Testing Company Address: PO Box 31465 Date of Testing/Servicing: 11/19/2008_ Page 1 of Xy Rev(2/08)