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For Use By All Jurisdictions Within the State of California MAR 1 7 2010 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations I v` ENT HESqH This form must be used to document testing and servicing of monitoring equipment. A separate certt i e prepared for each monitoring system control panel by the technician who performs the work. A copy of this orm mus VKMETwo 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: SOUTH BAY TIRE Bldg. No.: Site Address: 1501 W. CHARTER WAY City: STOCKTON I Zip: 95206 Facility Contact Person: MIKE EL/ASON Contact Phone No.: (209) 948-9412 Make/Model of Monitoring System: VEEDER-ROOT TLS -350 Date of Testing/Servicing: MAR 12, 2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Signature: Tank ID: DIESEL ® In -Tank Gauging Probe. Model: MAG Z In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 420 Z Annular Space or Vault Sensor. Model: 420 Z Piping Sump / Trench Sensor(s). Model: 208 Z Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: STP -MLD Z Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: FLAPPER / FLOAT Z Tank Overfill / High -Level Sensor. Model: FLAPPER / FLOAT ❑ Other (specify equipment e and model in Section E on Pae 2). ❑ Other (specify e ui ment type and model in Section 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: ❑ Others eci equipment a and model in Section E on Pae 2). 1 ❑ Other (speciLy a ui ment a and model in Section E on Pa Le 2). Dispenser ID: 1-2 Dispenser ID: 3_4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Floats and Chain(s). Z Dispenser Containment Floats and Chain(s). Dispenser ID: 5, 6A Dispenser ID: 6 - 7 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Floats and Chains . Z Dispenser Containment Floats and Chain(s). Dispenser ID: 7A 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). *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): MIKE LAWRENCE Signature: Certification No: A26642 I License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707) 446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testing/ ervicin MAR 12, 2010 Page 1 of 3 Monitoring System Certification