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MONITORING SYSTEM CERTIFICATION c Forl&e By All Jurisdictions Within the State of California Authority Cited. Chapter 6.7, HejWd Safety Code; Chapter 16, Division 3 Title 23, C is Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, 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: KAISER MANTECA Site Address: 1777 W YOSEMITE AVE Facility Contact Person: ENGINEERING MANAGER Make/Model of Monitoring System:OWENS CORNING B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced City: MANTECA CA Zip: 95337 Contact Phone No: 825-3460 Date of Testing/Service: 08/03/2011 Work Order Number: 2282466 Tank ID: DIE Tank ID: In -Tank Gauging Probe. Model: D In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: RS 10B Annular Space or Vault Sensor. Model: )( Piping Sump/Trench Senors). Model: L -S3 Piping Sump/Trench Sensor(s). Model: Fill Sump Senors). 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: 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: Tank ID: In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Senors). Model: Piping Sump/Trench Sensogs). Model: Fill Sump Senors). 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: 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 Dispenser ID: Dispenser Containment Sensors) Model: Dispenser Containment Sensors) Model: Shear Valve(s). Shear Valve(s) ID Dispenser Containment Float(s) and Chain(s). Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser lD: Dispenser Containment Sensors) Model: Dispenser Containment Sensors). Model: ❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser lD: Dispenser ID: ❑ Dispenser Containment Sensors) Model: Dispenser Containment Sensors). Model: Shear Valve(s). Shear Valve(s). ElDispenser 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the (Check all that apply): ❑ System set-up R Alarm history report Technician Name (print): JARROD COOKE Signature: Certification No.: 5311523 License. No.: 743160 (Class 'A' General Enginering Contractor License) Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 11000 N. MoPac Expressway, suite 500, Austin, TX 78759 Date of Testing/Servicing: 08/03/2011 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08