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MONIT&NG' SYSTEM CETI ATI07,,1 ` For Use Use By All Jurisdictions Within the State of California C*,,� t 41� Authority Cited.- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Californ`i�` '>Qde of Regulc%i��s r k` This form must be used to document testing and servicing of monitoring equipment. A separate certlficatidn!�he� 6nort must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form iY1tidbe,�r4vided 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 Si ature: Facility Name: RAMOS OIL Bldg. No.: Site Address: 10842 S. HARLAN RD 41:y: FRENCH CAMP Zip: 95231 Facility Contact Person: BRYAN JONSON ntact Phone No.: (916) 371-2570 Make/Model of Monitoring System: INCON TS 1000 Date of Testing/Servicing: OCT 18, 2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ected/serviced• Tank ID: DIESEL Si ature: 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: FXIOV / LD2000 ❑ 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: ❑ Other(specify equipment a and model in Section E on Pae 2). ❑ Other (specifX equipment e 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 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 (speciLy equipment a and model in Section E on Page 2). ❑ Other (specify a ui ment e and model in Section E on Pae 2). Dispenser ID: 14A Dispenser ID: 4-4A Z Dispenser Containment Sensor(s). Model: FLOAT Z Dispenser Containment Sensor(s). Model: FLOAT ® Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser 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). ❑ Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). 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). ❑ Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s). It 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): IZ System set-up Z Alarm history report _7Technician Name(print): ROBERT NEIMEYER Si ature: Certification No: 3647353760 License: 803705 Testing Company Name: TANK- TEK ENVIRONMENTAL CORPORATION Phone No: (707) 446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: OCT 18, 2007 Pagel of 3 Monitoring System Certification