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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 prepared 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 Signature: �____. _ Facility Name: CRLLC #5447 Bldg. No.: Site Address: 1469 E. HAMMER LANE City: STOCKTON Zi : 95209 Facility Contact Person: ALLEN FAASS Contact Phone No.: (925) 884-0800 Make/Model of Monitoring System: VEEDER-ROOT TLS -350 Date of Testing/Servicing: 7/15/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauioment inspected/serviced: Tank ID: 91 Signature: �____. _ Tank ID: 89 License: 803705 Z In -Tank Gauging Probe. Model: MAG Z In -Tank Gauging Probe. Model: MAG Z Annular Space or Vault Sensor. Model: 409 Z Annular Space or Vault Sensor. Model: 409 Z Piping Sump / Trench Sensor(s). Model: 208 Z Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD 2000 Z Mechanical Line Leak Detector. Model: FXIV ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: FLAPPER Z Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (s eci e ui ment type and model in Section E on Pae 2). ❑ Other (specify equipment e and model in Section E on Page 2). Tank ID: 87 Tank ID: DIESEL Z In -Tank Gauging Probe. Model: MAG Z In -Tank Gauging Probe. Model: MAG Z Annular Space or Vault Sensor. Model: 409 Z Annular Space or Vault Sensor. Model: 409 Z Piping Sump / Trench Sensor(s). Model: 208 Z Piping Sump / Trench Sensor(s), Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD 2000 Z Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: FLAPPER Z Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment e and model in Section E on Pa e 2 . El Other s eci e ui ment e and model in Section E on Pae 2). Dispenser ID: 11®2 Dispenser ID: 33®4 Z Dispenser Containment Sensor(s). Model: BEAUDREAU 406 Z Dispenser Containment Sensor(s). Model: BEAUDREAU 406 Z Shear Valve(s). Z Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: 55=6 Dispenser ID: 77®8 Z Dispenser Containment Sensor(s). Model: BEAUDREAU 406 Z Dispenser Containment Sensor(s). Model: BEAUDREAU 406 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9 - 10 Dispenser ID: Z Dispenser Containment Sensor(s). Model: BEAUDREAU 406 ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats 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 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 Z Alarm history report Technician Name(print): RICHARD THOMAS Signature: �____. _ Certification No: 834022 7 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION 1 Phone No: (707) 446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: 7/15/2011 Page I of 3 Monitoring System Certification