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ONIT ING SYSTEM CEI CATION 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 monitorings, stem 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 Facility Name: SOUTH BAY TIRE Bldg, No.: Site Address: 5101 W. CHARTER WAY City: STOCKTON Zip: 95206 Facility Contact Person: MIKE ELIASON Contact Phone No.: (209) 948-9412 Make/Model of Monitoring System: INCON TS100 Date of Testing/Servicing JUNE 21, 2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a uiment inspected/serviced Tank ID: REGULAR Tank ID: Z In-Tank Gauging Probe. Model: MAG ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Motel:FLOAT ❑Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s), Model:FLOAT ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: STP-MLD ❑Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: FLOAT ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specifX e ui ment ty2e and model in Section Eon Pa e 2 . ❑Other(specify equipment e and model in Section E on Pae 2). Tank ID:DIESEL Tank ID: Z In-Tank Gauging Probe. Model: MAG ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor, Model: FLOAT ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: FLOAT ❑Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: STP-MLD ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model:FLOAT ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipmenttype and model in Section E on Pae 2). ❑ Other(specify equipment type and model in Section E on Pae 2). Dispenser ID: 1_2 Dispenser ID: 7;8 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s)and Chains . Z Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3_4 Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑Shear Valve(s). Z Dispenser Containment Floats and Chain(s). ❑Dispenser Containment Floats and Chain(s). Dispenser ID: 55-66 Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s), Model: Z Shear Valve(s). ❑Shear Valve(s), Z Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include i iformation for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/service.{ in ccordance with the manufacturers' guidelines. Attached to the Certification is information(e.g. manufacturers' checklists) necessary to ierify 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 ❑ Alarm history report —7Technician Name(print): ROBERT NEIMEYER Signature: = - Certification No: 06043717 License: 803705 Testing Company Name: TANK-TEK .NVIRONMENTAL CORPORATION Phone No: (707)446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: JUNE 21, 2007 Page 1 of 3 Monitoring System Certification