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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 monitoring system 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 Signature:�� Facility Name: VALLEY PACIFIC CARDLOCK #152 Bldg. No.: Site Address: 930 E. VICTOR RD City: LODI Zip: 95240 Facility Contact Person: MIKE ELIASON Contact Phone No.: (209) 948-9412 Make/Model of Monitoring System: ►NOON TS2001 Model: FLOAT I Date of Testing/Servicing: JUNE 29, 2006 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: REGULAR Signature:�� Tank ID: License: 803705 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: FXIV ❑ 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 (speciLy a ui ment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). Tank ID: SUPER Tank ID: ® In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: ® 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: FXIV ❑ 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 (s eci a ui ment type and model in Section E on Pae 2). ❑ Other (specify equipment e and model in Section E on Pae 2). Dispenser ID: 11=2 Dispenser ID: 7_8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). Z Shear Valve(s). Z Dis enser Containment Floats and Chain(s). Z Dispenser Containment Floats and Chain(s). Dispenser ID: 33=4 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑ Shear Valve(s). Z Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 55=6 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑ Shear Valve(s). Z Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Float(s) 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 the 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): Z System set-up Z Alarm history report Technician Name (print): ROBERT NE/MEYER Signature:�� Certification No: 06043717 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATIONPhone No: (707) 446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testin Servicin JUNE 29, 2006 Page 1 of 3 Monitoring System Certification