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MONT*RING SYSTEM CERTIFIRFATION For Use By All Jurisdictions Within the State of California Authority Cited.• Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regrll�att�ns�� This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prephtidi monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank systert4 owns(/t�per�tor. 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: Mister Cafe -Valero Bldg.No.: Site Address: 713 N EI Dorado St City: Stockton Zip: 95202 Facility Contact Person: Contact Phone No.: (209) Make/Model of Monitoring System: TLS 35OR Date of Testing/Servicing: 4/27/2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: T 1 UNLEADED Tank ID: T2 PREMIUM Z In-Tank Gauging Probe. Model: 847390-109 ®In-Tank Gauging Probe. Model: 847390-109 Z Annular Space or Vault Sensor. Model: 794380-302 ®Annular Space or Vault Sensor. Model: 794380-302 Z Piping Sump/Trench Sensor(s). Model: 0794380-208 Z Piping Sump/Trench Sensor(s). Model: 0794380-208 Z Fill Sump Sensor(s). Model: 0794380-208 Z Fill Sump Sensor(s). Model: 0794380-208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: 8484 Z Electronic Line Leak Detector. Model: 8484 ❑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: T 3 DIESEL Tank ID: Z In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794380-302 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 0794380-208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: 0794380-208 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: 8484 ❑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). Dispenser ID: 1/2 Dispenser ID: 3/4 Z Dispenser Containment Sensor(s). Model: 0794380-208 Z Dispenser Containment Sensor(s). Model: 0794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 718 IRI Dispenser Containment Sensor(s). Model: 0794330-201 ®Dispenser Containment Sensor(,), Model: 0794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 Z Dispenser Containment Sensor(s). Model: 0794380-208 Z Dispenser Containment Sensor(s). Model: 0794380-208 Z Shear Valve(s). Z 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 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 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): ® System set-up ® Alarm history report Technician Name(print): Gavin Williams Signature: Certification No.: 5285969-UT License.No.: 856771 Testing Company Name: HMC -Henderson Maintenance Company Phone No.:(209) 467-7573 Site Address: 713 N EI Dorado St Date of Testing/Servicing: 4/27/2007 Page 1 of 3