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Q1-13-09; 01 : 53PM;T0WN & 010RING TRY CONTRACTORS ; 916-636-9507 4 5 MO 1C SYSTEM CERTI AT1ON For Use By if 11 Jurisdictions <d,'ithin the State of California Authority Cited:• Chapter 6.7, Health and Safety Code; Chapter 161 Division 3, Title 23, California Code afRegulations This form must be used to document testing and Servicing of monitoring equipment. A se itrale certift n n Q -ennrt must be me nrcd for each mani[oritti? systenLcotLral navel by the technician who perforins the work. A copy of this form must be provided to the tank systenl ovvnerlopertator. 'Clic oxvner/operator must submit a copy of tht o ¢ ating UST systems within 30 days of test date. i General Information AU07 2 2008 Facility Naive: CDSTCO#103'1 Bldg. No.: B Y:. j Site Address: 2440 DANIELS RD. --- ---.0 L1G_MANTBCA Zip: Facility Contact Person: Contact Phone No.: ( ) Makc/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 8/12/08 B. Inventory of Equipment Tested/Certified Check the appronjaw boxes to Indicate a ecitic cl ul nictlt il"VectL([I9L'l„Iccd4: Tank ID: 87A Mmlc ID: 87B X Tri-Tank Gauging Probe, Model: 107 X In-'rank Gauging Probe, Model: 107 X Annular Space or Valtlt Sensor. Model: 303 X Annular Space or Vault Sensor. Model: 303 X Piping Sulnp/Treach Sensor(s). Model: 112 X Piping Sump/Trench Sensor(s). Model: 112 X rill Sump Scnsor(s). htodol: 112 X Fill Sump Scnsor(s). Ltodal: 112 ❑Meclimical Linc Lcak Detector, Model: � ❑Mechanical Line Lcak Dctectar. Model: X Electronic Lino Leak Dciector, Modal: PLLD X Electronic Line Leak octector, Model: PLLD Q Tank Overfill I High-I.—I Sensor. Model: ❑ Tank Overfill I High-Lovol$ca.ior. Model; El Other(sl?ccify equipment type and nlodct in section E on Pago 2). ❑ other(snccity equipment type awed model in Section 1 an Pngo 2}, Tana:ID: 91 Tank 1D; X In•Tank Gauging Probe, Model: 107 ❑In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Modcl: 303 0 Annular Space or Vault Sciisor. lvfodel: X Piping Sump/Trench Senaot(a), Model: 112 ❑Piping Sump/Trencli Scnsor(s). Miodal: ,r X Fill Sump 5ensor(s), Models 112 ❑ Fill Sump sensor(s). Ivtodal: ❑ Mcchanical Linc Leak Douctor. Model: Q Mcchnniml Lille Lcak Detector. Model; ?( Gleetronic Lille Lcuk Detector. Model: PI-LD 'p Electronic Lisle Look Dcloetor. Model: �F ❑ Tank Overfill I High-Level Sensor. Model: ❑Tank Overfill/High•Lovol Sensor. Model: ❑ other(specify equipment type and model in Section L' on Page 2). ❑Other(specify equipment type and model in Scction E eti Page 2). Dispenser Z[): 1&2 3&4 Dispenser ID: 58,6 7&8 % Dispense€Containment Scnser(s), Mocict: 323 X DispcnRr Containment Senwr(s). 'Model: 523 X Slicer valve(s). X Shear valve(s). ❑ Dispeasar Containmcat Float(s)and Chain(s), ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9&10 D'asponser LD: 11&12 X Dispenser Containment Sensor(s), Model: 323 X Dispenser Contairinwit Scn9or(s). Model. 323 X Shear Volve(s). X Sltear valve(s). ElDtspon.cr Contaim'Yient Flows)and Chanl(s). 0 Dispenstr Contaiauncnt t-loat(S)gild Chain(s). Dispenser ID: 13&.14 Dispenser ID: 15&16 X Diapenscr Contairunent Scmor(s), Model: 323 X Dixpenscr Contairaaent 5otasor(•s}. Model: 323 X Shear Vidvc(s), X Shen Valve(s). ❑ Dispen�r Containment Floats)and Chain(s}. ❑Dispenser Containment Float(s)acid Chain(s), •If the facility contains more tanks or dispensers,copy thus[omi. Include information for Lavery tank and dispenser at the facility, C. Certification - r certify that the equipment identiRed in this document ;vas Inspectod/scrvlced in aceordnnco with the i tnslaul'acturers' 1 uidelines, Attach( to this Certification is information (e.g. manufacturers' checklists} necessary to•ver fy that this inf'ormution is correct and :t Plan shoring tho layout of monitoring cquiptnent. For son ,equiptnunt cnprtblo Pf ge rating each cheek utt tirvr a 1 X m ,117 X Alar t 0 Peliort reports,I have also tittached a copy of the report; ( FPY�:rte Technician Name PATRICK MULHALL Signature Ccrtificatian No, 633136 Licensc, N .: 4 5 Testing Company Name: B. Z. Service Station Maintenance Plione No.: 916 371.2380 Site Address: 630 Houston Street West Sacramento, CA 96691 Date of Testing/Servicing: 8/12108 Page 1 of 3 I UN-036-1/4 w•mv.unidues.org Rev.6=16/06 L