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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: SOUTH BAY TIRE Bldg. No.: Site Address: 1501 W. CHARTER WAY City: STOCKTON I Zip: 95206 Facility Contact Person: MIKE ELIASON Contact Phone No.: (209) 948-9412 Make/Model of Monitoring System: INCON TS1000 I Date of Testing/Servicing: JUN 5, 2008 B. Inventory of Equipment Tested/Certified Signature: Check the aggropriate boxes to indicates ecific a ui ment inspected/serviced: Tank ID: 87 Tank ID: Z In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 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: Z Mechanical Line Leak Detector. Model: STP -MLD ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLOAT ❑ Tank Overfill / High -Level Sensor. Model: ❑ Others eci a ui ment ty2e and model in Section E on Pae 2). ❑ Others eci equipment a and model in Section E on Page 2). Tank ID: DIESEL Tank ID: Z In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 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: ® Tank Overfill / High -Level Sensor. Model: FLOAT ❑ Tank Overfill / High -Level Sensor. Model: ❑ Others eci a ui ment a and model in Section E on Pa e 2 . ❑ Other (s2ecify a ui ment =e and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 66=7 ❑ 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 Chains . Dispenser ID: 334 Dispenser ID: 7A ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ® Shear Valve(s). Z Dispenser Containment Floats and Chains . Z Dis enser Containment Floats and Chains . Dispenser ID: 5 - 6A 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 Floats and Chains . *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 ❑ Alarm history report Technician Name (print): ROBERT NEIMEYER7 Signature: Certification No: 3647353760 1 License: 803705 Testing Com anName: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707) 446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: JUN 5, 2008 Page 1 of 3 Monitoring System Certification