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MONITCNG SYSTEM CERTIACATION 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: TOWER MART#876 Bldg. No.: Site Address: 14000 E. HWY88 City: LOCKEFORD I Zip: 95237 Facility Contact Person: MOHAMMAD AFZAL Contact Phone No.: (209) 727-5442 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: APR 23,2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecitic equipment inspected/serviced: Tank ID: 87 Tank ID: 91 Z In-Tank Gauging Probe. Model: MAG Z In-Tani-Gauging Probe. Model:MAG Z Annular Space or Vault Sensor. Model:420 Z Annular Space or Vault Sensor. Model:420 Z Piping Sump/Trench Sensor(s). Model: 208 Z Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model:_ ❑Fill Sump Sensor(s). Model:_ Z Mechanical Line Leak Detector. Model:STP-MLD Z Mechanical Line Leak Detector. Model:STP-MLD ❑Electronic Line Leak Detector. Model:_ ❑Electronic Line Leak Detector. Model:_ Z Tank Overfill/High-Level Sensor. Model:FLOAT Z Tank Overfill/High-Level Sensor. Model:FLOAT ❑Other(specify equipment a and model in Section E on Pae 2).. ❑Other(specify equipment a and model in Section E on Pae 2). Tank ID:DIESEL Tank ID:_ 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: STP-MLD ❑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(specia a ui ment type and model in Section E on Pae 2). 1 ❑Other(specify a ui meat a and model in Section E on Pae 2). Dispenser ID: 1_2 Dispenser ID:33=4 Z Dispenser Containment Sensor(s). Model:208 Z Dispenser Containment Sensor(s). Model:208 Z Shear Valve(s). Z Shear Valve(s). Z Dis enser Containment Floats and Chain (s). Z Dispenser Containment Floats and Chain(s . Dispenser ID: 5_6 Dispenser ID: 7_8 Z Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Floats and Chain(s). Z Dispenser Containment Floats and Chains . Dispenser ID:_ Dispenser ID:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser 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 ® Alarm history report Technician Name(print): MIKE LAWRENCE Signature: Certification No:A26642 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707)446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testin Servicin : I APR 23, 2008 Page 1 of 3 Monitoring System Certification