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MONITAING SYSTEM CERTIATION 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: TIME OIL#04-049 Bldg. No.: Site Address: 14000 E. HWY88 City: LOCKEFORD I Zip: 95237 Facility Contact Person: CHUCK SOFTICH Contact Phone No,: (800)426-0235 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: APR 3, 2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s ecifie equipment inspected/serviced: Tank ID: REGULAR Tank ID: DIESEL 0 In-Tank Gauging Probe. Model:MAG ® In-Tank Gauging Probe. Model:MAG 0 Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model:420 ®Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: STP-MLD ® 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 ty e and model in Section E on Pagc 2). ❑ Other(specify equipment e and model in Section E on Pae 2). Tank ID: SUPER Tank ID: 0 In-Tank Gauging Probe, Model:MAG ❑ In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 420 ❑Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: STP-MLD? ❑Mechanical Line Leak Detector. Model: Electronic Line Leak Detector, Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: FLOAT ❑Tank Overfill/High-Level Sensor. Model: Other(s2ecify equipment ty e and model in Section E on Pae 2). ❑Other(specify equipment e and model in Section E on Pae 2). Dispenser ID: 11-22 Dispenser ID: 77-88 ❑Dispenser Containment Sensor(s). Model: 208 1Z Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s). ®Shear Valve(s). ®Dispenser Containment Float(s)and Chains ®Dispenser Containment Floats and Chain(s}, Dispenser 1D: 3-44 Dispenser ID: ®Dispenser Containment Sensor(s). Model: 208 ❑Dispenser Containment Sensor(s). Model: M Shear Valve(s). ©Shear Valve(s). Z Dis enser Containment Floats and Chains . ❑Dispenser Containment Floats and Chain (s). Dispenser ID: 55-66 Dispenser ID: Dispenser Containment Sensor(s). Model: 208 ❑Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)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): ® System set-up Alarm history report Technician Name(print): ROBERT NEIMEYER Signature: Certification No: 000-19-8246 1 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION -71 Phone No: (707)446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testin Servicin APR 3, 2007 Page I of 3 Monitoring System Certification