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MONITOUNG SYSTEM CERTIFIOkTION 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 servici � t A separate certification or reportmust be prepared for each monitoring_system control panel by the technician who pe�fd ftethis 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 JUN I no 2007 Facility Name: Fremont Shell - � Bldg.No.: Site Address: 2494 E. Fremont ST ' City: Stockton Zip: 95205 Facility Contact Person: Mike Contact Phone No.: (209) 941-8743 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 6/14/2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins cted/serviced: Tank ID: T-1 Regular Tank ID: T-2 Supreme ®In-Tank Gauging Probe. Model: 847000-109 ®in-Tank Gauging Probe. Model: 847000-109 ®Annular Space or Vault Sensor. Model: 304 ®Annular Space or Vault Sensor. Model: 304 ®Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ®Fill Sump Sensor(s). Model: 208 ®Fill Sump Sensor(s). Model: 208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: 8484 ®Electronic Line Leak Detector. Model: 8484 ❑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: 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(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: 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). 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). 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,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(print): Gavin Williams Signature: Certification No.: WIKT2074 License.No.: 05857 Testing Company Name: C-Henderson Maint Co Phone No.:(209) 7-7573 Site Address: PO Box 31325, Stoickton, CA 95213 Date of Testing/Servicing: 6/14/2007 Page 1 of 3