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MONIT&dNG SYSTEM CERTIFIATION For Use By All Jurisdictions Within the State of California 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 certification or report must be prepared for each monitoring Ustem 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. I Opt A. General Information Facility Name: Unified Western Grocers 2608 Bldg.No.: Site Address: 1990 Piccoli Street City: Stockton zip: 95215 1'-A,T- �� Facility Contact Person:Pat Quill ENV1R0N " i h SALT H Contact Phone No.:(123).264-5200 PERNNI,T/ -RVI Make/Model of Monitoring System:Veeder-Root TLS 350 CES Date of Testing/Servicing: 12/22/2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate spIFifiEll!!E2!E2L!2sEcted/serviced. Tank ID:T I —Diesel Tank ID:T 2—Diesel rx-1 In-Tank Gauging Probe. Model:847390-107 13 In-Tank Gauging Probe. Model: ®R Annular Space or Vault Sensor. Model:794390-420 13 Annular Space or Vault Sensor. Model: IM Piping Sump/Trench Sensor(s). Model:794380-208 U Piping Sump/Trench Sensor(s). Model: L3 Fill Sump Sensor(s). Model: U Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model:FE Petro E3 Mechanical Line Leak Detector. Model: L3 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: 13 Tank Overfill/High-Level Sensor. Model: E3 Other(specify equipment type and model in Section E on Page 2). Q Other(specify�guipment�Te and model in Section E on Page 2). Tank ID:T 3—Waste Oil Tank ED: 0 In-Tank Gauging Probe. Model: 13 In-Tank Gauging Probe. Model: Q Annular Space or Vault Sensor. Model: L] Annular Space or Vault Sensor. Model: U Piping Sump/Trench Sensor(s). Model: U Piping Sump/Trench Sensor(s). Model: L3 Fill Sump Sensor(s). Model: E3Fill Sump Sensor(s). Model: U Mechanical Line Leak Detector. Model: U Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: L3 U Electronic Line Leak Detector. Model: Q Tank Overfill High-Level Sensor. Model: L3 Tank Overfill/High-Level Sensor. Model: ❑ El other(TeciLuipmente and model in Section E on Pe 2 ® Other(specify equipment type and model in Section E on Page 2). a!�A !jT2g ) Dispenser ID:Dispenser 01 Dispenser ID: 0 Dispenser Containment Sensor(s). Model:794380-420 El Dispenser Containment Sensor(s). Model: 21 Shear Valve(s). Q Shear Valve(s). L3 Dispenser Containment Floats and Chain(s). UDispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ED: Ll Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: El Shear Valve(s). Q Shear Valve(s). L]Dispenser Containment Float s)and Chain(s). E3 Dispenser Containment Flo221(9 and Chain s). Dispenser ID: Dispenser ID: U Dispenser Containment Sensor(s). Model: E3 Dispenser Containment Sensor(s). Model: E3 Shear Valve(s). Q Shear Valve(s). 013igenser Containment Float s)and Chain(sL._ I Q DiTenser Containment Floaqs)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. manufacturersAbecklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any� q ipment capable generating such reports,I have also attached a copy of the report;(check all that apply): Ul System set-up histo r ort Technician Name(print):Asa Cosby Signature: Z Certification No.:A-22350 License.No.:A-HAZ_(&381 Testing Company Name:A&J Environmental Svc's Inc. Phone No.:(951) 681-OW8 Site Address: 1990 Piccoli Street Stockton, Ca 95215 Date of Testing/Servicing: 12/22/2008 Page 1 of 3 03/01