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HEMMED MONITbUING SYSTEM CERTIFI*mATION For Use By All Jurisdictions Within the State of California MAY 32 p 2008 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations ENVIRONMENT HEALTH This form must be used to document testing and servicing of monitoring equipment.A separate certification-0-P! ed for each monitorine system control panel by the technician who performs the work. A copy of this form must be pi edrovto a 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: ESTES Trucking Bldg.No.: Site Address: 7611 S.Airport Way City: Stockton Zip 95206 Facility Contact Person: Jim Bunek or Mark Hancock Contact Phone No.: 714-893-6140 Make/Model of Monitoring System:Veeder-Root TLS 350 Date of Testing/Servicing: May 27,2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: #1 DIESEL Tank ID: In-Tank Gauging Probe. Model: Mag Probe ❑ In-Tank Gauging Probe. Model: (x)Annular Space or Vault Sensor. Model: 794380-302 ❑ Annular Space or Vault Sensor. Model: (a)Piping Sump/Trench Sensor(s). Model:794380-208 O Piping Sump/Trench Sensor(s). Model:_ U Fill Sump Sensor(s). Model: ❑ Fill Sump Sensors). Model:_ ()Mechanical Line Leak Detector. Model: 0 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 Pae 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: #2 Tank ID: ( )In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: LI Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 1] Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: U 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 specil equipment type and model in Section E on Pae 2). ❑ Other(specify a ui ment a and model in Section E on Page 2). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model:. _ Shear Valve(s). ❑ Shear Valve(s). ( )Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats and Chains . Dispenser ID: #1 Dispenser ID: Dispenser Containment Sensor(s). Model: BRAVO ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). U Shear Valve(s). 17 Dispenser Containment Floats and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: L3 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ODis enser Containment Floats and Cham(s). O Cis enser Containment Fioat(s)and Ch..in(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,1 have also attached a copy of the report;(check all that apply): (x)System set-up (x)Alarm history report Technician Name(print): Eric Molgaard Signature.: Eric Norgaard Certification No.: ICC 5250200-UT,Veeder-Root 27995 License No.: 309105 Testing Company Name:STOCKTON SERVICE STATION EQUIPMENT CO. INC. Phone No 209-464-8333 Site Address: 7611 S.Airport Way,Stockton,CA 95206 Date of Testing/Servicing:May 27,2008 Page 1 of 4 03/01 Monitoring System Certification