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ONIT NG SYSTEM CERTIRCATION 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: CRLLC#2705446 Bldg. No.: Site Address: 1403 COUNTRY CLUB BLVD City: STOCKTON Zip: 95204 Facility Contact Person: ARMEN MKRTYTCHIAN Contact Phone No.: (925)884-0800 Make/Model of Monitoring System: VEEDER-ROOT TLS-350I Date of Testing/Servicing: MAY 13, 2010 B. Inventory of Equipment Tested/Certified F ro riate boxes to indicates ecific a ui ment ins ected/serviceIESEL Tank ID:87 auging Probe. Model:MAG Z In-Tank Gauging Probe. Model:MAG Space or Vault Sensor. Model:303 Z Annular Space or Vault Sensor. Model:303 mp/Trench Sensor(s). Model: 208 Z Piping Sump/Trench Sensor(s). Model:208 Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model:LD 2000 Z Mechanical Line Leak Detector. Model:LD 2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model:FLAPPER/FLOAT Z Tank Overfill/High-Level Sensor. Model:FLAPPER/FLOAT ❑Other(specifyequipment e and model in Section E on Pa e 2 . ❑Other s ecify e ui ment ty e and model in Section E on Pa e 2). Tank ID:91 Tank ID: Z In-Tank Gauging Probe. Model:MAG ❑ In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model:303 ❑Annular Space or Vault Sensor. Model: Z 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/FLOAT [I Tank Overfill/High-Level Sensor. Model: ❑Others eci equipment e and model in Section E on Page 2 . ❑Other(s eci e ui ment type and model in Section E on Pae 2 . Dispenser ID: 1_2 Dispenser ID:334 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Dispenser Containment Floats and Chains . ®Shear Valve(s). Z Dis enser Containment Floats 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 Chains . Z Dispenser Containment Floats and Chains . 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 Chains . ❑Dis enser 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 Z Alarm history report Technician Name(print): MIKE LAWRENCE :]:S:Zignature: Certification No:A26642 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No: (707)446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testin /Servicin MAY 13, 2010 Page 1 of 3 Monitoring System Certification