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MONITORING SYSTEM CERTIFICATION 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 Regulations This form must be used to document testing and servicing of monitoring equipment.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 form 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: Mr. Cafe' Bldg.No.: Site Address: 713 North EI Dorado Street City: Stockton Zip: 95202 Facility Contact Person: Fred Esfandiary Contact Phone No.: 408 807-9839 Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: 02 /03 /05 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/sen iced: Tank ID: Gasoline-87 'rank ID: Gasoline-91 ■ In-Tank Gauging Probe. Model: Mag Probe ■ In-Tank Gauging Probe. Model: Mag Probe ■ Annular Space or Vault Sensor. Model: 794380-303 ■ Annular Space or Vault Sensor. Model: 794380-303 ■ Piping Sump/Trench Sensor(s). Model: 794380-208 ■ Piping Sump/Trench Sensor(s). Model: 794380-208 ■ Fill Sump Sensor(s). Model: 794380-208 ■ Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ■ Electronic Line Leak Detector. Model: o84848o-oot ■Electronic Line Leak Detector. Model: o84848o-ool ❑ Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Pae 2). 1 ❑Other(specify equipment e and model in Section E on Pae 2). 'rank ID: Diesel Tank ID: ■ In-Tank Gauging Probe. Model: Mag Probe ❑ In-Tank Gauging Probe. Model: ■ Annular Space or Vault Sensor. Model: 794380-303 ❑Annular Space or Vault Sensor. Model: ■ Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Piping Sump/Trench Sensor(s). Model: ■ Fill Sump Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ■ Electronic Line Leak Detector. Model: omm8o-oot ❑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). 1 ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ■ Dispenser Containment Sensor(s). Model: 794380-208 ■ Dispenser Containment Sensor(s). Model: 794380-208 ■ Shear Valve(s). ■ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 1D: 5-6 Dispenser 1D: 7-8 ■ Dispenser Containment Sensor(s). Model: 794380-208 ■ Dispenser Containment Sensor(s). Model: 794380-208 ■ Shear Valve(s). ■ 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 ■ Dispenser Containment Sensor(s). Model: 794380-208 ■ Dispenser Containment Sensor(s). Model: 794380-208 ■ Shear Valve(s). ■ Shear Valve(s). ❑Dis enser 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 apptv): Q System set-up X //Il�grm history report Technician Name(print): Phillip Klingman Signature: Certification No.: 006-05-0809 License.No.: 617238 Testing Company Name: Walton Engineering,Inc. Phone No.:( 916 ) 373-1152 Site Address: 3900 Commerce Drive,West Sacramento,CA 95691 Date of Testing/Servicing: 02 / 03 / 05 UN-036-1/4 Page 1 of 3 Rev.06/04/01 CUPA: San Joaquin County Environmental WALTON INSPECTOR: Dina Craw oaGINEERING, INC. www.unidocs.org