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MONFOPUNG SYSTEM CERTIFWTION 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 Drepared o monitoring_ system control anel by the technician who performs the work. A copy of this form must be provided to the D The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test da P=Vt. A. General Information Facility Name: Hammer Lane Oil Inc. Site Address: 3304 W. Hammer Lane Facility Contact Person: Mike Gurm Make/Model of Monitoring System: Veeder Root B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauipment inspected/serviced: "MWEEEEALTH City: Stockton K ! C- S Contact Phone No.: (209) 992-1415 Date of Testing/Servicing: 6/24/2010 Tank ID: T1: 87 Tank ID: T2: 91 ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: 10 Annular Space or Vault Sensor. Model: 794390-420 (spill tank) Annular Space or Vault Sensor. Model: 794390-420 (spill tank) Piping Sump / Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Model: 794380-208 11 Fill Sump Sensor(,). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FE Petro STP -MLD 0 Mechanical Line Leak Detector. Model: FE Petro STP -MLD ❑ 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: T3: Diesel Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390-420 ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: R.J. FXIDV ❑ Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: El Tank Overfill / High -Level Sensor. Model: El 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: 1+2 Dispenser ID: 3+4 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). 2 Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5+6 Dispenser ID: 7+8 El Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). Z Dispenser Containment Float(s) 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, copv this form. Include information for every tank and disnenser 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 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): Guadalupe Sanchez Signature: Z- Certification No.: A30138 License. No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Phone No.: (209) 845-9657 Testing Company Address: 521 Branding Iron St. Date of Testing/Servicing: 02412010 Page 1 of 3 Rev (2/08)