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MONITORING SYSTEM CERTIFICATION For Use By AIf Jurisdictions ifrthin 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.If more than one monitoring system control panel is installed at the facility,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: Save On Gas Bldg.No.: Site Address: 420 W. Yosemite Ave. City: Manteca Zip: 95337 Facility Contact Person: Sam Contact Phone No.: 209-267-4400 Make/Model of Monitoring System: Veeder-Root/TLS-3000 Date of Testing/Servicing: 4.11-2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate a nt ment W ed/seniced.: Tank ID: Unleaded 87/91 Tank ID: ®ht-Tank Gauging Probe. Model: (2)847790-707 ®in-Tank Gauging Probe. Model: ®Annular Space or Vault Senor, Model: 734390409 ❑Annular Space or Vault Sensor. Model: ®Piping Sump)Trench Sensor(s)_ Model: (2)794380-208 ❑Piping Sump/Trench Sense% Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensors} Model: ❑Mechanical line Lett Detector. Model: ❑ Mechanical Line leak Detector. Model: ❑Electronic Lune teak Defector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Serena. Model: ❑Other(specify equipment type and model in Section E on Page 2} ❑other(specify equipment type and model in Section Eon Page 2). Tank ID: Tank ID: ❑In Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault SCRSOr. Model: ❑Annular Space or Vault Serear. Model: ❑ Piping Sump/Trench Scmo(s)_ Model: ❑Piping Sump/Trench Semm(s} Model: ❑Fill Sump Senson(s} Model: ❑Fill Sump Sensors). Model: ❑Mechanical tiro UA Detector. Model: ❑Mechanical Line teak Detector. Model: ❑Electronic Lina Leak Detector. Model: ❑Eled cat;Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model m Section E on Page 2). ❑Other(sp-*equipmeat type and model m Section E on Page 2), Dispenser ID: 1/2 Dispenser ID: 3/4 ❑ Dispenser Containment Sema(,). Model: ❑Dispenser Conmmment Sensor(s). Model: ®Shear Valve(s} ®Shear Valve(s). ®Dispenser Containment Floats)and Chars). ®Dispenser Containment Floal(s)and Chain(,). Dispenser ID: Dispenser ID: ❑Disperser Containment Smson(a). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s} ❑Dispenser Containment Float(s)and Chars). ❑Disposer Comainm ent Float(s)and Chain(.} Dispenser ID: Dispenser ID: ❑Dispenser Coraamm m Sensors} Model: ❑Dispeaso Commune nt Sezor(s). Model: ❑Shear Valve(s). ❑Shear Valves). ❑Digser Conlaimnmt Floats)and Chain(,} ❑Disposer Containment Float(.)and Chars) *If the facility contains more tanks or dispensers,copy this form Include information for every lank 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 equrent. For any equipment capable of generating such reports,I have also attached a copy of the report;(check ail that apply): System set-up �larm history report Technician Name Brian Thornton Signature: j'77 —7 Certification No.: A31562 License No.: CSLB#724513 ICC#5024962 Testing Company Name: Thomton Environmental Construction, Inc. Phone No.: (209)834-0792 Testing Company Address: P.O. Box 360833 Milpitas, CA 95036 Date of Testing/Servicing: 4-11-2013 Page 1 of 3