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FW0N1T(%NG SYSTEM CERTIACATION 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 Tank ID: 91 Facility Name: CRLLC #2705448 Bldg. No.: Site Address: 3202 W. HAMMER LANE City: STOCKTON Zip: 95209 Facility Contact Person: ARMEN MKRTYTCH/AN Contact Phone No.: (925) 884-0800 Make/Model of Monitoring System: VEEDER-ROOT TLS -350 Date of Testing/Servicing: FES 19, 2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment insnected/serviced: Tank ID: 87 Tank ID: 91 Certification No: B34022 I Z In -Tank Gauging Probe. Model: MAG Z In -Tank Gauging Probe. Model: MAG Z Annular Space or Vault Sensor. Model: 409 Z Annular Space or Vault Sensor. Model: 409 Z Piping Sump / Trench Sensor(s). Model: 208 Z Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: STP -MLD Z Mechanical Line Leak Detector. Model: STP -MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specifZ e ui ment e and model in Section E on Pae 2 . ❑ Other(specify e ui ment e and model in Section E on Pae 2). Tank ID: DIESEL Tank ID: ® In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other(specify a ui ment ty2e and model in Section E on Pae 2). ❑ Other(specify equipment tye and model in Section E on Pae 2). Dispenser ID: 1-2 Dispenser ID: 3_4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dis enser Containment Floats and Chain(s). Z Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5_6 Dispenser ID: 7®8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Floats and Chain(s). Z Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). 11 ❑ Dispenser Containment Floats 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 the 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): Z System set-up ® Alarm history report Technician Name (print): RICHARD THOMAS Signature: Certification No: B34022 I License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707) 446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: FEB 19, 2010 Page 1 of 3 Monitoring System Certification