COMPLIANCE INFO JAN 2016 - MAY 2016

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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 ofRegulatidns This form must be used to document testing and servicing of monitoring equipment. A separate certification or re ort must r 216 monitoring system control Panel by the technician who performs the work. A copy of this form must be provided to the tank system o o er t 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 FacilityName: VALLEY PACIFIC CARDLOCK#152 Bldg.No.: Site Address: 930E VICTOR ROAD City: LODI Zip: 95240 Facility Contact Person: MIKE ELIASON Contact Phone No.: (209)948.9412 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: 3/23/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T6 87 Tank ID: T7 87 Z In-Tank Gauging Probe. Model VR MAG PLUS Z In-Tank Gauging Probe Model VR MAG PLUS Z Annular Space or Vault Sensor. Model VRA20 Z Annular Space or Vault Sensor Model VR 420 Z Piping Sump/Trench Sensor(s) Model VR 208 Z Piping Sump/Trench Sensor(s) Model VR 208 ❑Fill Sump Sensor(s) Model ❑Fill Sump Smsor(s). Moder Z Mechanical Line Irak Detector Model LD2000 Z Mechanical Line Leak Detector Moder LD2000 ❑Electronic Line Leak Detector. Model ❑Electronic Line Leak Detector Model Z Tank Overfill/High-Level Sensor Model FLAPPER VALVE ®Tank Overfill/High-Level Sensor Model FLAPPER VALVE ❑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: Tank ID: ❑In-Tank Gauging Probe Model- ❑In-Tank Gauging Probe. Model ❑Annular Space or Vault Sensor Model ❑Annular Space or Vault Sensor Model [I Piping Sump/Trench Sensor(s) Model: El Piping Sump/Trench Sensor(s). Model ❑Fill Sump Sensor(s) Model ❑Fill Sump Sensor(s). Model ❑Mechanical lane Leak Detector Model ❑Mechanical Line teak Detector Model ❑Electronic Line Leak Detector Model. ❑Electronic Line Leak Detector Model. ❑Tank Overfill/High-Level Sensor Moder ❑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 ❑Dispenser Containment Sensor(s). Model. ❑Dispenser Containment Sensor(s). Model ®Shear Valve(s) Z Shear Valve(s) ®Dispenser Containment Float(s)and Cham(s) Z Dispenser Containment Float(s)and Cham(s) Dispenser ID: Dispenser ID: ❑Dispenser Containment Semor(s) Model, ❑Dispenser Containment Sensor(s) Model ❑Shear Valve(s) ❑Shear Valves) ❑Dispenser Containment Float(s)and Cham(s) ❑Dispenser Containment Float(s)and Cham(s). Dispenser ID- Dispenser 1D: ❑Dispenser Containment Sensor(s). Model ❑Dispenser Containment Sensor(s) Model ❑Shear Valve(s) ❑Shear Valve(s) ❑Dispenser Containment Floats)and Chaints). ❑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 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): RICHARD THOMAS Signature: 1.—a. Certification No.: 5012133701 License.No.: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No.:(707)779-4999 Testing Company Address: P.O.BOX 5850,RIVERSIDE, CA 92517-5850 Date of Testing/Servicing: 3/23/2016