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Monitoring steCertification 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 system within 30 days of test date. A. General Information \ Facility Name:Lathrop Shell Bldg.No.: Site Address: 16500 S Harlan Rd. City: Lathrop,CA Zip: 95330- Facility Contact Person: Manager Contact Phone No.: (209)983-0381 Make/Model of Monitoring System: WR TLS-350 Date of Testing/Servicing: 12/5/13 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank IDL 01-Prem Tank ID-02-Regu ❑ In-Tank Gauging Probe. Model ❑ In-Tank Gauging Probe. Model: 11 Annular Space or Vault Sensor. Model: VR 794390409 Annular Space or Vault Sensor. Model: VR 794399.409 11 Piping Sump\Trench Sensor(s). Model: VR 794390209 ® Piping Sump\Trench Sensor(s). Model:- VR 794390.209 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: p 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 equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 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 Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. 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 equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 01-02 Dispenser IR: 03-04 ❑ 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). Dispenser ID• 06-06 Dispenser ID• 07-06 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model Q Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). [LDn IQ: Dispenser ID• r Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: lve(s). p Shear Valve(s). r 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 manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'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; (checkaff that apply): ❑ System set-up ❑ Alarm history report Technician Name(print):Kris Bell Signature. Mfg.Cert.#.: B33709 ICC# 5297793-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 Date of Testing/Servicing: 12/5113