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ONIT NG SYSTEM CETI CATION 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: RAMOS OIL Bldg.No.: Site Address: 10842 S.HARLAN ROAD City: FRENCH CAMP I Zip: 95231 Facility Contact Person: DAVE NELSON Contact Phone No.: (916)371-3289 Make/Model of Monitoring System: INCON TS 1000 Date of Testing/Servicing: OCT 10, 2008 B. Inventory of Equipment Tested/Certified Check the a2propriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID:DIESEL Tank ID: Z In-Tank Gauging Probe. Model:MAG ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model:FLOAT ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model:FLOAT ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model:FLOAT ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model:LD 2000/FX10V ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model:FLOAT ❑Tank Overfill/High-Level Sensor. Model: El Other s eci equipment a and model in Section E on Pae 2). 1 ❑Other(specify a ui ment ty2e and model in Section E on PML2). 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 Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). 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�specft equipment a and model in Section E on Pa e 2). ❑ Other(speciLy a ui ment a and model in Section E on Pae 2). Dispenser ID: 1-1A Dispenser ID:4-4A Z Dispenser Containment Sensor(s). Model:FLOAT Z Dispenser Containment Sensor(s). Model:FLOAT Z Shear Valve(s). Z Shear Valve(s). ❑Dis enser Containment Floats and Chains . ❑Dis enser Containment Floats and Chain (s). Dispenser ID:2-2A Dispenser ID:5-5A Z Dispenser Containment Sensor(s). Model:FLOAT Z Dispenser Containment Sensor(s). Model:FLOAT Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Floats and Chain (s). ❑Dispenser Containment Floats and Chains . Dispenser ID:3-3A Dispenser ID: Z Dispenser Containment Sensor(s). Model:FLOAT ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Floats and Chain (s). ❑Dis enser Containment Floats and Chains . *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):ROBERT NEIMEYER Signature: Certification No: 3647353760 License: 803705 Testing Company Name: TANK TEK ENVIRONMENTAL CORPORATION I Phone No: (707)446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: I OCT 10,2008 Pagel of 3 Monitoring System Certification