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MONIA�JNG SYSTEM CERTIF*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 c i r.• must be. re ared for each monitoring system control panel by the technician who perforans the work. A copy of this st r� i Il � i to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating U tvdH n 0`dd�s6ftest date. A. General Information JUL 1 7 2008 Facility Name: Texaco cnlvlQnnlhgFligl Site Address: 1405 Califoria St City: Escalon PFRMIT/SFR11!9W 95320 Facility Contact Person: Donna Contact Phone No.: (209) 499-2693 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 711512008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates cific equipment ins ected/serviced: Tank ID: T-1 UNL Tank ID: T-2 SUPER IR In-Tank Gauging Probe. Model: 265152020 Ia In-Tank Gauging Probe. Model: 265152020 ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: E Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Senscr(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: FXIV ®Mechanical Line Leak Detector. Model: FXIV ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Defector. Model: ❑Tank Overfill/High-Level Sensor. Model: 1 ❑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). TanktD: T3 Diesel Tank ID: ®In-Tank Gauging Probe. Model: 265152020 ❑ In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Seasons). Model: ❑Fill Sump Sensor(s). Model: ID Mechanical Line Leak Detector. Model: FXIV ❑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 made[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 Semor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ®Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensm(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Floats)and Chards). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Semsor(s). Model: ❑Dispenser Containment Seasons). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Floats)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 Gavin Williams Signature: Certification No.: 5285969-UT License.No.: 856771 Testing Company Name: HMC-Henderson Maintenance Company Phone No.:(209) 467-7573 Site Address: Date of Testing/Servicing: 7/15/2008 Page 1 of 3