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ONI ING SYSTEM CERTIFIO&TION 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 ta_-1k 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 FacilityName: SOUTH BAY TIRE Site Address: 1501 W. CHARTER WAY Facility Contact Person: MIKE ELIASON Make/Model of Monitoring System: VEEDER-ROOT TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eouioment inspected/serviced: City: STOCKTON Bldg. No.: Zip: 95206 Contact Phone No.: (209) 948-9412 Date of Testing/Servicing: 312312011 Tank ID: 87 Tank ID: DIESEL N In -Tank Gauging Probe. Model: MAG N In -Tank Gauging Probe. Model: MAG N Annular Space or Vault Sensor. Model: 420 N Annular Space or Vault Sensor. Model: 420 N Piping Sump / Trench Sensor(s). Model: 208 N Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: STP -MLD N Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Tank Overfill / High -Level Sensor. Model: FLOAT/FLAPPER N Tank Overfill / High -Level Sensor. Model: FLOAT I FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Sectim E on Page 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 (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1 - 2 Dispenser ID: 3 - 4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). N Shear Valve(s). N Dispenser Containment Float(s) and Chain(s). N Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5, 6A Dispenser ID: 6 - 7 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). N Shear Valve(s). N Dispenser Containment Float(s) and Chain(s). N Dispenser Containment Float(s) and Chain(s). Dispenser ID: 7A Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). N 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 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): ® System set-up ® Alarm history report Technician Name (print): MIKE LAWRENCE Certification No.: A26642 Signature: License. No.: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No.: (707) 446-6151 Testing Company Address: 607 ELMIRA ROAD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: 3/23/2011 Page 1 of 4 UN -036 — www.unidoes.org Rev. 01/17/08