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MONITCOING SYSTEM CERTI4A 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 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 Si nature: Facility Name: COUNTRY MARKET Bld . No.: Site Address: 1524 FRESNO AVENUE ICi : STOCKTON I Zip: 95206 Facility Contact Person: MIKE ELIASON I Contact Phone No.: (209) 948-9412 Make/Model of Monitoring System: VEEDER-ROOT TLS -350 I Date of Testing/Servicing: JUN 22, 2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific enninment insnPeted/epruir4d• Tank ID: DIESEL Si nature: Tank ID: Certification No: A26642 Z In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: Z Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD 2000 ❑ 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 (specifX a ui ment e and model in Section E on Page 2). ❑ Other (s2ecify e ui ment jUe and model in Section E on Pa e 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 a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Dispenser ID: 1A Dispenser ID: 1 - 2A Z Dispenser Containment Sensor(s). Model: V/R STAND-ALONE Z Dispenser Containment Sensor(s). Model: V/R STAND-ALONE Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chains . Dispenser ID: 2 - 3A Dispenser ID: 3=4 Z Dispenser Containment Sensor(s). Model: V/R STAND-ALONE Z Dispenser Containment Sensor(s). Model: V/R STAND-ALONE Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispense r 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 Si nature: Certification No: A26642 License: 803705 Testing Company Name: TANK TEK ENVIRONMENTAL CORPORATION Phone No: (707) 446-6151 Address: 607 ELMIRA RD, PMB 336, VA CAVILLE, CA 95687 Date of Testing/Servicing: JUN 22, 2009 Page] of 3 Monitoring System Certification