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KV MONIT&UNG SYSTEM CERTIFIWTI 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, CaliforniAckdf"Fations This form must be used to document testing and servicing of monitoring equipment. A separate certificatiok-bN",6"- ie �for.each monitoring system control panel by the technician who performs the work. A copy of this form must W*U4*d,1jVj@#3rtank 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: Fremont Shell Bldg.No.: Site Address: 2494 E. Fremont Street -—- City: Stockton Zip: 95205 Facility Contact Person: Mike Contact Phone No.: (209) 941-8743 Make/Model of Monitoring System: TLS-360 Date of Testing/Servicing: 71812008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate sp!cific!2uiL-ent inspected/serviced: Tank I : T-1 FNular Tank ID: T-2 Supreme 0 in-Tank Gauging Probe. Model: 109 0 In-Tank Gauging Probe. Model: 109 0 Annular Space or Vault Sensor. Model: 304 0 Annular Space or Vault Sensor. Model: 304 10 Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: 208 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: ED Electronic Line Leak Detector. Model: 8484 0 Electronic Line Leak Detector. Model: 8484 [I Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: Ej Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Tank I : Tank I : 0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: [I Annular Space or Vault Sensor. Model: [I Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: [I Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: [I Tank Overfill/High-Level Sensor. Model: ❑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: 314 [R Dispenser Containment Sensor(s). Model: 208 10 Dispenser Containment Sensor(s). Model: 208 ED Shear Valve(s). 0 Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). F-1 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 516 Dispenser ID: 718 0 Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 Shear Valve(s). 0 Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: [I Dispenser Containment Sensor(s). Model: [I Dispenser Containment Sensor(s). Model: [I Shear Valve(s). [I Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). [I 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 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 Gavin Williams Signature: Certification No.: 6285969-UT License.No.: 856771 Testing Company Name: HMC-Henderson Maintenance Company Phone No.:(209) 467-7573 Site Address: Date of Testing/Servicing: 7/812008 Page 1 of 3