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MONITSING SYSTEM CERTIFII'TION 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 #5446 Bldg. No.: Site Address: 1403 COUNTRY CLUB BLVD City: STOCKTON Zip: 95204 Facility Contact Person: ALLEN FAASS Contact Phone No.: (925) 884-0800 Make/Model of Monitoring System: VEEDER-ROOT TLS -350 / RONAN X76S Date of Testing/Servicing: 5/18/2012 B. Inventory of Equipment Tested/Certified Check the iteeropriate boxes to indicatespecific a ui Ment inspected/serviced: Tank ID: DIESEL Tank ID: 87 Z In -Tank Gauging Probe. Model: MAG Z In -Tank Gauging Probe. Model: MAG Z Annular Space or Vault Sensor. Model: 302 Z Annular Space or Vault Sensor. Model: 302 Z Piping Sump / Trench Sensor(s). Model: 208 Z Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD2000 ® Mechanical Line Leak Detector. Model: LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: 91 Tank ID: WASTE OIL Z In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 302 Z Annular Space or Vault Sensor. Model: LS -30 ® Piping Sump / Trench Sensor(s). Model: 208 Z Piping Sump / Trench Sensor(s). Model: LS -3 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: 1/2 Dispenser ID: 3/4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s) and Chain(s). Z Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 718 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s) and Chain(s). Z 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 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): Z System set-up Z Alarm history report Technician Name (print): RICHARD THOMAS Signature: Certification No.: B34022 License. No.: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No.: (707) 446-6151 Testing Company Address: 607 ELMIRA ROAD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: 5/18/2012 Page 1 of 4 UN -036 — www.unidocs.org Rev. 01/17/08