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MONITORING SYSTEM CERTIFICATION 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 Regulationv This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be p=aced for each monitoring system control panel by the technician who performs the work. A copy of this form mitst 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. Genemi Information Facility Name: SBC Site Address: 907 LINCOLN ROAD Facility Contact Person: JEFF LAVA / CALVIN MUIR GEO PAR # UE -046 CLLC Code: SKTNCAI I City: STOCKTON Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS -350 B. Inventory of Equipment Testeci/Certified Cherk the sinnranriate boxes to indicate specific equipment inspected/serviced: Zip: 559-442-2120 / 209-943-4128 Date of Testing/Service: 8/17/05 Tank ID: 1171 Tank ID: ®In -Tank Gauging Probe: Model: 847390-107 ❑In -Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 794390-420 []Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensor (s): Model: 794380-352 []Piping Sump/Trench Sensor (s): Model: ®Fill Sump Sensor (s): Model: 794380-352 []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: FEDERAL 350 ❑Tank Overfill/High-level Sensor: Model: ❑Other, Specify a uia and model in Section E on Pae 2 ❑Other, S eci a ui . e and model in Section E on Pa e 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, §pecify Specifya ui . =e and model in Section E on Page 2 ❑Other, Specify a ui a and model in Section E on Pa e 2 Dispenser ID: Dispenser ID: []Dispenser Containment Sensor(s): Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chains []Dispenser Containment Floats and Chats) Dispenser ID: Dispenser ID: []Dispenser Containment Sensor(s): Model: _ []Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) ❑Dis enser Containment Floats and Chain s Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s): Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chains ❑Dis enser Containment Floats 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): ® Systecp.se history report Technician Name (Print): RUBEN BECERRA Signature: Certification No.: 0042 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222