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MONITORING SYSTEM CERTIFICATION 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 l2anel 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. Genera! Information Facility Name: UNITED #f5446 Bldg. No.: Site Address: 1403 COUNTRY CLUB BLVD City: STOCKTON Zip: 95204 Facility Contact Person: ALLEN FAASS Contact Phone No.: (949) 289-5286 Make/Model of Monitoring System: VEEDER-ROOT TLS -350 Date of Testing/Servicing: 5/11/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: DIESEL Tank ID: 87 Z In -Tank Gauging Probe. Model VR MAG 1 Z In -Tank Gauging Probe. Modcl VR MAG 1 ® Annular Space or Vault Sensor Model VR 302 Z Annular Space or Vault Sensor Model. VR 302 ® Piping Sump / Trench Sensor(s) Model VR 208 Z Piping Sump / Trench Sensor(s). Model- VR 208 ❑ Fill Sump Sensor(s) Model ❑ Fill Sump Sensor(s) Model ® 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 VALVE Z Tank Overfill / High -Level Sensor Model FLAPPER VALVE ❑ 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: Z In -Tank Gauging Probe, model. VR MAGI ❑ In -Tank Gauging Probe Model. Z Annular Space or Vault Sensor Model VR 302 ❑ Annular Space or Vault Sensor Model. Z Piping Sump / Trench Sensor(s) Model VR 208 ❑ Piping Sump / Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model. ❑ Fill Sump Sensor(s) Model - 0 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 VALVE ❑ 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. Z Shear Valve(s) Z Shear Valve(s). Z Dispenser Containment Float(s) and Cham(s) Z Dispenser Containment Float(s) and Cham(s) Dispenser ID: 516 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 Float(s) and Chain(s) Z Dispenser Containment Float(s) and Cham(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 Cham(s) ❑ Dispenser Containment Float(s) and Cham(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, 1 have also attached a copy of the report; (check al/ that apply): ® System set-up ® Alarm history report Technician Name (print): RICHARD THOMAS Signature: l:.__ -z A Certification No.: 5012133701 License. No.: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No.: (707) 779-4999 Testing Company Address: P.O. BOX 5850, RIVERSIDE, CA 92517-5850 Date of Testing/Servicing: 5/11/2016