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MONITORING SYSTEM CERTIFICATION 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 Facility Name: Shell 1-5 Bldg. No.: Site Address: 717 W. Eighth St. City: Stockton Zip: 95206 Facility Contact Person: Owner Contact Phone No.: (209) 939-0961 Make/Model of Monitoring System: Veederoot TLS350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Date of Testing/Servicing: 3/5/2014 Tank ID: #1 -Regular Tank ID: #2 -Premium ® In -Tank Gauging Probe. Model: 847390-109 ® In -Tank Gauging Probe. Model: 847390-109 ® Annular Space or Vault Sensor. Model: 794390-302 ® Annular Space or Vault Sensor. Model: 794390-302 w Split tank ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Mechanical Line Leak Detector. Model: Veederoot FX1 V ® Mechanical Line Leak Detector. Model: VMI LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: ATG ® Tank Overfill / High -Level Sensor. Model: ATG ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: #3 -Diesel Tank ID: Z In -Tank Gauging Probe. Model: 847390-109 ❑ In -Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: Split tank w/Prem ❑ Annular Space or Vault Sensor. Model: Z Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: Veederoot FX1 DV ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: ATG ❑ 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 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑ 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): Jeff Conger Signature: Certification No.: A22219 License. No.: ICC# 1801782 UT CSLB# 894932 Testing Company Name: Pinnacle Fuel Compliance Services, Inc. Phone No.: (408) 206-9840 Testing Company Address: P.O. Box 32849 San Jose, CA 95152-2849 Date of Testing/Servicing: 3/5/2014 Page 1 of 3