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PETRO-1*HZ ENVIRONMENTALWRVICRECEIVED MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California JUN 20 2011 Authority Cite&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 certificatio ni Mel for each monitoring system control panel by the technician who performs the work. A copy of this form must S9prove Ne 'tot Ttank 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: UNITED PARCEL SERVICE Date of Certification/Testing Services:6/14/2011 Site Address: 1532 NORTH BROADWAY City/State:STOCKTON.CA Zip:95205 Facility Contact Person:KASI MONTGOMERY-PLANT ENGINEERING Contact Phone No.:(916)708-6616 Make of Monitoring System:VEEDER-ROOT TLS-350, Model No.:0847090-022 Serial No.:UNAVAILABLE B. Inventory of Equipment Tested/Certified Check the acc=riate boxes to indicate seecific equipment inspected/serviced: Tank ID: Tl:DIESEL 0 Annular Space or Vault Sensor. Model: Ll:Veeder-Root N 302 Tank Comments: S Piping Sump/Trench Sensor(s). Model: L2:Veeder-Root#208 0 Mechanical Line Leak Detector. Model: Vgorless 991D2000 0 Electronic Line Leak Detector. Model: • Tank Overfill/High-Level Sensor. Model: • Other(specifX eguipment5 e 2). ,Te and model in Section E on Pae Dispenser ID: #1-2 DIESEL Dispenser Comments: Dispenser Containment Sensor(s). Model:Yeeder-Root N 001 Shear Valve(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 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 M Alarm history report Technician: Dan Zeman Signature Company Name:PETRO-TECHZ Environmental Services Company Address: P.O.Box 29 Paradise,CA 95967-2941 Company Phone and Fax No.:(530)680-2905 Fax: (530)872-8648 SB Tank Tester License No.:#98-1535 Veeder-Root Certification No.:A32807 Exp.,4/2012 ICC,CA UST Service Technician Certification No.:5243781-UT Date/Time of Certification Services:6/14/2011 k 9:00 am Inspector Present(Name):Jeff Wong-S.J.Co.E.H.D. Page 1 of 5