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AlItech 17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320; Fax: 209-533-2650 California Tank Tester: 90-1068 California Contractor +623541 A-Haz alltech@mlode.com A. General Information Facility Name: Mossdale Exxon Date of Testing/Servicing: July j#, 2003 Facility Address: 444 Mossdale Rd., Lathrop CA Facility Contact Person: Nick Bokides Contact Phone No.: 234-1256 LIA: San Joaquin; Ray von Flue Make/Model of Monitoring System: Veeder-Root TLS -350 B. Inventory of Equipment Tested/Certified: Check the appropriate boxes to indicate specific eauloment insnected/seryiced: Tank 1D: Regular Compartment Tank TD: Supreme Compartment ® In= Tank Gauging Probe. Model: Mag 1 ® In -Tank Gauging Probe. Model. Mag 1 ® Annular Space or Vault Sensor. Model: Float Switch (Shared) ® Annular Space or Vault Sensor. Model: (Shared) M Piping Sump / Trench Sensor(s). Model: Liquid sensor ® Piping Sump / Trench Sensor(s). Model: Liquid sensor ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: Red Jacket XL M Mechanical Line Leak Detector. Model: Red Jacket XL, ❑ Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: Drop Tube ® Tank Overfill / High -Level Sensor. Model: Drop Tube ❑ Other ❑ Other Tank ID: Diesel Compartment Tank ID: M In -Tank Gauging Probe. Model: Mag 1 ❑ In -Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: Shared ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: Liquid sensor ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: Red Jacket XL. ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor, Model: Drop Tube ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other ❑ Other Dispenser ID: 1&2 M Sump: MDry []Water ❑Product Dispenser ID: 3&4 M Sump: ®Dry ❑ Water E] Product M Dispenser Containment Sensor(s). Model: Liquid sensor M Dispenser Containment Sensor(s). Model: Liquid sensor ® Shear Valve(s) (Functional test) ® Shear Valve(s) (Functional test) ❑ Disvenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5&6 M Sump: MDry []Water ❑Product Dispenser ID: 7&8 ® Sump: ®Dry ❑Water ®Product ® Dispenser Containment Sensor(s). Model: Liquid sensor ® Dispenser Containment Sensor(s). Model: Liquid sensor ® Shear Valvc(s) (Functional test) ® Shear Valve(s) (Functional test) ❑ Dis enser Contaimnent Floats and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9&10 ® Sump: MDry []Water ❑Product Dispenser ID: 11&12 M Sump: ®Dry ❑Water ❑Product ® Dispenser Containment Sensor(s). Model: Liquid sensor M Dispenser Containment Sensor(s). Model: Liquid sensor M Shear Valve(s) (Functional test) M Shear Valve(s) (Functional test) ❑ Dis enser Containment Floats and Chain(s). Dis enser Containment Float(s) and Chain(s). 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: Mike Dotten, California Coro TR.A-c_-Tz? (p �� 3S`` / i A `11*4 Z Certification: Veeder-Root: 341-32-6743; Level 3. Page 1 of 3 03101 S.d 0992—EE9 (602) saltW R,4Tje4O dGa:90 co tj inC