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ONITO SYSTEM CERTIFIC ' ION For Use 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 monjjgdgg`astern 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 this date. A. General Information Facility Name: Yosemite 76 Bldg.No.: Site Address: 1700 Yosemite Avenue City: Manteca Zip: 95336 Facility Contact Person: Amba Rai Contact Phone No.: 925-756-1210 Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: 4/5/2006 B. Inventoryy of Equipment Tested/Certified Check the appropriate boxes to indicate spedtic equipment inspected/serviced; Tank ID: 12OW gal.FtWular Tank ID•12OW gal.Super [X] In-Tank Gauging Probe. Model:847390-107 [x) In Gauging Probe. Model: 847390-107 [x] Annular Space or Vault Probe. Model:-7 -420 Lx] Annular Space or Vault Sensor. Model: 794390.420 [x] Piping Sump/Trench Sensor(s). Model:794380-208 [x] Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s). Model: [x I Mechanical Line Leak Detector. Model:VMI [x] Mechanical Line Leak Detector. Model: VMI ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Ix-1 Tank Overfill/High Level Sensor. Model:OPW 61 SO [x] Tank Overfill/High Leval Sensor. Model: OPW 61-SO ❑ Other(specify equip.type and model in Sec.E on Pg.2) ❑ Other(specify equip.type and model in Sec.E on Pg.2) Tank ID: Tank ID: ® In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensors(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Decector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High Level Sensor. Model: ❑ Tank Overfill/High Level Sensor. Model: ❑ Other(specify equip.type and model in Sec.E on Pg.2) ❑ Other(specify equip.typs and model in Sec.E on Pg.2) Dispenser ID: 1&2 Dispenser ID: 3&4 [x Dispenser containment Sensor(s). Model: 794380-208 [x] Dispenser Containment Sensor(s).Model: 794380-208 [x] Shear Valve(s). [X] Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s) Dispenser ID: 6&6 Dispenser ID: 7&8 Lx] Dispenser Containment Sensor(s).Model: 794380-208 ❑ Dispenser Containment Sensor(s).Model: 794380-208 [x] Shear Valve(s). [x] Shear Valve(s). ❑ Dispenser Containment Float(s)and Chains(s). ❑ 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 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 ins services in accordance with the manufacturers'guidlines.Attached to this Certification is information(e.g.manufacturers'checklist)necessary to varify that this information is correct and a plot plan showing the layout of monitoring equipment.For equipment capable of generating such reports,I have attached a copy of the report;(check all that apply) x❑Sys t-u Alarm history report Technician Name(print): Douglas M.Young III Signature: LIU Certification No: 006-05-0333 License No: emqm Testing Company Name: Confidence UST Services,Inc. Phone No: 800-339-9930 Site Address: 1700 Yosemite Avenue,Manteca,CA 95336 Date of Testing/Servicing: 4/5/2006