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MONITORING SYSTEM CERTIFICATION 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 forth 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: Shell 1-5 Bldg.No.: Site Address: 717 W. Eighth St. City: Stockton Zip: 95206 Facility Contact Person: Owner Contact Phone No.: (209) 939-0961 Make/Model of Monitoring System: Veederoot TLS350 Date of Testing/Servicing: 3/5/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID:_#1-Regular Tank ID: #2-Premium ®In-Tank Gauging Probe. Model: 847390.109 M In-Tank Gauging Probe. Model: 847390-109 M Annular Space or Vault Sensor. Model: 794390-302 M Annular Space or Vault Sensor. Model: 794390-302 w Split tank M Piping Sump/Trench Sensor(s). Model: 794380-208 M Piping Sump/Trench Sensor(s). Model: 794380.208 M Fill Sump Sensor(s). Model: 794380-208 M Fill Sump Sensor(s). Model: 794380-208 ®Mechanical Line Leak Detector. Model: Veederoot FX1 V M Mechanical Line Leak Detector. Model: VMI LD2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: M Tank Overfill/High-Level Sensor. Madel: ATG 1 M Tank Overfill/High-Level Sensor. Model: ATG ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: #3-Diesel Tank ID: M In-Tank Gauging Probe. Model: 847390.109 ❑In-Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: Split tank w/Prem ❑Annular Space or Vault Sensor. Model: M Piping Sump/Trench Seasons). Model: 794380-208 ❑Piping Sump/Trench Seasons). Model: ®Fill Sump Sensor(s). Model: 794384208 ❑Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: Veederoot FX1 DV ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: M Tank Overfill/High-Level Sensor. Model: ATG ❑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). Dispenser ID: 1-2 Dispenser ID: 3-4 M Dispenser Containment Sensor(s). Model: 794380-208 M Dispenser Containment Seasonal. Model: 794384208 M Shear Valve(s). M Shear Valve(s). ❑Dispenser Containment Hoat(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 M Dispenser Containment Sensor(s). Model: 794380-208 M Dispenser Containment Sensor(s). Model: 794380-208 M Shear Valve(s). M Shear Valve(s). ❑Dispenser Containment Hcaus)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 M Dispenser Containment Sensor(s). Model: 794380.208 M Dispenser Containment Sensor(s). Model: 794380-208 M Shear Valve(s). M 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(print): Jeff Conger Signature: ---�- l a---- Certification No.: A22219 License.No.: ICC#1801782 UT CSLB#894932 Testing Company Name: Pinnacle Fuel Compliance Services Inc. Phone No.: (408) 206-9840 Testing Company Address: P.O. Box 32849 San Jose, CA 95152-2849 Date of Testing/Servicing: 3/5/2014 Page 1 of 3