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MONIT*UNG SYSTEM a • 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 Rrepared 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 Si ature: Facility Name: RAMOS OIL Bldg. No.: Site Address: 10842 S. HARLAN RD City: FRENCH CAMP I zip: 95231 Facility Contact Person: BRYAN JONSON Contact Phone No.: (916) 371-2570 Make/Model of Monitoring System: INCON TS1000 Date of Testing/Servicing: OCT 9, 2006 B. Inventory of Equipment Tested/Certified Si ature: Check the ageroeriate boxes to indicatespecific a ui meat inspected/serviced: Tank ID: DIESEL Tank ID: ® In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: FLOAT ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: FLOAT ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: FLOAT E3Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FXI ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLOAT ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other �sgecLfLecLuipment type and model in Section E on P!&e 2). ❑ Others eci equipment a and model in Section E on Pa e 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 &cia equipment a and model in Section E on Pae 2). ❑ Other �s2eci& a ui ment a and model in Section E on Page 2). Dispenser ID: 1 - 1A Dispenser ID: 4 - 4A ® Dispenser Containment Sensor(s). Model: FLOAT ® Dispenser Containment Sensor(s). Model: FLOAT ® Shear Valve(s). ® Shear Valve(s). ❑ Dis enser Containment Flo!s and Chains . ❑ Dispenser Containment Floats and Chain(s), Dispenser ID: 2 - 2A Dispenser ID: 5 - 5A ® Dispenser Containment Sensor(s). Model: FLOAT ® Dispenser Containment Sensor(s). Model: FLOAT ® Shear Valve(s). ® Shear Valve(s). ❑ Dis enser Containment Floats and Chains . ❑ Dis enser Containment Floats and Chains . Dispenser ID: 3 - 3A Dispenser ID: ® Dispenser Containment Sensor(s). Model: FLOAT ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment FloLtjs2 and Chains . ❑ Dis enser Containment Floats 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 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): ® System set-up ® Alarm history report Technician Name rint : ROBERT NEIMEYER Si ature: Certification No: 04013868 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: OCT 9, 2006 Pagel of 3 Monitoring System Certification