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MONITAUNG SYSTEM CERTIFATION 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 gparate certification or EMgq must bepreParea for each monitoring system control panel by the technician who perfbnns 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 Facility Name: Unified Western Grocers Bldg. No.: Site Address: 1990 Piccoli Road City: Stockton zip: 95215 Facility contact Person: Pat Quillermety Contact Phone No.: 209-931-1990 Make/Model of Monitoring System: Veeder-Root TLS 350 Date of Testing/Servicing: 11-21-06 B. Inventory of Equipment Tested/Certified Check the a ro nate boxes to indicate sMific Equipment ins pected/serviced. Check 'j Tank inD: T I — Diesel Tank ID: Tank M I T 7 Gauging g PrU In -Tank Gauging Probe. Model: M rIn-Tank Gauging Probe. Model: 847390-109 W r 'r V E3 Annular Space or Vault Sensor. Model: W Annular Space or Vault Sensor. Model: 794390-42 0 in. S T0 Piping Sump / Trench Sensor(s). Model: Mp D 0 Piping Sump Trench Sensor(s). Model: 794380-208 0 Fill Sump Sensor(s). Model: U Fill Sump Sensor(s). Model: E3 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: STM -MLD 13 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: U Tank Overfill / High -Level Sensor. Model: U Other (specify equipment type and model in Section E on Page 2). 0 OthIrtgec!a!Sui ment!ae and model in Section E on P 2). TankID: Tank ID: U 14 -Tank Gauging Probe, Model: L) In -Tank Gauging Probe. Model: 13 Annular Space or Vault Sensor. Model: L) Annular Space or Vault Sensor. Model: • Piping Sump / Trench Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: • Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: • Mechanical Line, Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: [3 Electronic Line Leak Detector. Model: 13 Tank Overfill / High -Level Sensor. Model: El Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment type and model in Section E on Page 2). U Other (specify equipment type and model in Section E on Page 2). Dispenser iw: Dispenser 01 Dispenser ID: IM Dispenser Containment Sensor(s). Model: 794390-420 0 Dispenser Containment Sensor(s). Model: M Shear Valve(s). E3 Shear Valve(s). E3 Dispenser Containment F12!t2 and Chaina. QDispettser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID; U Dispenser Containment Sensor(s). Model: E3 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). U Shear Valve(s). UDiWenscr Containment F12!!W and ChajnA. U DiTContainment F12!V and C"s2., Dispenser ED: Dispenser ID: 13 Dispenser Containment Sensor(s). Model: L1 Dispenser Containment Sensor(s). Model: U Shear Valve(s). E3 Shear Valve(s). UDiMenser Containment E2!gs) and Chains . 0 Dispenser Containment 1`12 W 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' guideline& Attached to this Certification is information (eg. manufact necessary to verify that this information is ur ' correct and a Plot Plan showing the layout of monitoring equipment. For any ent capable f ,* generating such reports, I have also attached a copy of the report, (ckeck all that apply): 0 System set-up EAZarm his M7;=n� Technician Name (print): Asa Cosby Signature: Certification No.: 006-05-2126 License. No.: A-HAZ_6 I Testing Company Name: A& J Environmental Svc's Inc. Phone No.: 95 I i 691-0-A Site Address: 15015 Valley View Ave.. Santa Fe Springs. CA. 90670 Date of Testing/Servicing. A 1-21-06 Page 1 of 3 0"1