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A . MON401ING SYSTEM CERTI k. ATION 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: Site 300---- 131d1g.No.: 879 Site Address: Corral Hollow City: Tracy Zip: 95376 Facility Contact Person: Beverly Morales Contact Phone No.: (925) 422-7481 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 9/19/2007 B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to indicatespecific equipment inspected/serviced: Tank ID: #I Unleaded Tank ID: ®In-Tank Gauging Probe. Model: pao2651320200 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390-420 ❑Annular Space or Vault Sensor. Model: M Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: Vaporless ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: Veeder-Root ❑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: #2 Diesel Tank ID: ®In-Tank Gauging Probe. Model: pao2650960200 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: pao2591144000 ❑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: ❑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: Veeder-Root ❑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: Tokheim 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). Dispenser ID: Tokheim 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). Dispenser ID: Tokheim 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 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 story report Technician Name(print): Gregg Geltz Signature: Certification No.: 5250561-UT License.No.: 491948 Testing Company Name: Central Petroleum Maintenance Phone No.: (b25) 462-4060 Site Address: 176 Wyoming Street, Pleasanton, CA 94566 Date of Testing/Servicing: 9/19/2007 Page 1 of 3 UN-036—1/4 www.unidocs.org Rev.01/26/06