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MONIT NG SYSTEM CERTIRUTION e By All Jurisdictions Within the State of Califomi Authority Cited:Chapter 6.7,H and Safety Code;Chapter 16,Division 3 Title 23, omia 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 opntrol 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 forth to the local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: ULTRAMAR 492 City: MANTECA CA Zip:95336 Site Address: 470 N MAIN ST Contact Phone No: 823-1344 Date of Testing/Service: 11/22/2005 Facility Contact Person: MANAGER Make/Model of Monitoring System:TLS350 Work Order Number: 2239393 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Inspected/serviced TanklD: 1 TanklD: 2 X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: 420 71 Piping Sump/Trench Sensor(s). Model: 208 Piping Sumprrrench Sensor(s). Model: 206 X Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: FX1 V Mechanical Line Leak Detector. Model: FX1V 71 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OverfilUHigh-Level Sensor. Model: 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). TanRID. TanklD: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OverfilVHigh-Level Sensor. Model: Tank Overfill/High-Leval 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[L): 1/2 Dispenser ID: 3/4 QDispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: X❑Shear Valve(s). X Shear Valve(s) QX Dispenser Containment Float(s)and Chain(s). X Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser UID.. 7/8 MDispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Xi Shear Valve(s). Shear Valve(s). X Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser IU: Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)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 Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): ❑X System set-upX❑Alarm history report Technician Name(print): RHOME DESBIENS Signature: i Certification No.: 1938 License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 11/22/2005 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification