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OI NG SYSTEM CE TIFI 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 ++awe certification or reoort must be ®reoared for each monitoring s ststem 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 34 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) 00 Make/Model of Monitoring System: VEEDER-ROOT TLS -350 Date of Testing/Servicing: 511512014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates cific Mulpment IU ted/serviced: Tank ID: 87 ing Probe. Model: MAG ® in -Tank Gauging Probe. Model: MAG FID:SEL or Vault Sensor. Model: 302 ® Annular Space or Vault Sensor_ Model: 302 / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ll Sumpensor(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 Lime Leak Detector. Model: ® 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: ® In -Tank Gauging Prof. Model: MAG ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 302 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ 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: ® Tank Overfill / High -Level Seng. 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: 112 Dispenser ID: 314 ❑ Dispenser Containment Sen"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: 516 Dispenser ID: 718 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Modei: ® Shear Valve(s). Shear Valve(s). ® Dispenses Containment Float(s) and Chain(s). ® Dispenser Containment Floats) 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 aulpment. For any eq ur ment capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up ii Alarm history report Technician Name (print): RICHARD THOMAS Signature: 1�-5 Certification No.: B34022 License. No.: 803705 Testing Company Name: TANK TEK ENVIRONMENTAL CORPORATION Phone No.: f70i) 446-6151 Testing Company Address: 607 ELMIRA ROAD, PM8 336, VACA VILLF, CA 95687 Date of Testing/Servicing: 5115/2014 Page 1 of 4 UN -W6 — www.unidocs.org Rev. 01/17/08