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MONIT" NG�SYSTEitM hin CEthetRTIFI�TION %wClse By of Caliticin 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: USA #110 Site Address: 2132 MARIPOSA ROAD City: STOCKTON Contact Phone No: 946-9282 Date of Testing/Service: 05/03/2004 Facility Contact Person: DEALER Make/Model of Monitoring System:VEEDER-ROOT Work Order Number: 2230833 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95205 Tank ID: PREMIUM Tank ID: PLUS X In -Tank Gauging Probe. Model: MAG -1 X In -Tank Gauging Probe. Model: MAG -1 X Annular Space or Vault Sensor. Model: 794390-407 Annular Space or Vault Sensor. Model: 794390-407 X Piping SumprTrench Sensor(s). Model: 794380-208 Piping Sump/Trench Sensor(s). Model: 794380-208 X Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380-208 Mechanical Line Leak Detector. Model: FX1 V Mechanical Line Leak Detector. Model: FX1 V Electronic Line Leak Detector. Model: Electronic Line Leak Detecto, Model: Tank Overfill/High-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). Tank ID: Tank ID: DIESEL X In -Tank Gauging Probe. Model: MAG -1 In -Tank Gauging Probe. Model: MAG -1 X Annular Space or Vault Sensor. Model: 794390-407 Annular Space or Vault Sensor. Model: 794390-407 X Piping Sump(Trench Sensor(s). Model: 794380-208 Piping Sump/Trench Sensor(s). Model: 794380-208 X Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380-208 X Mechanical Line Leak Detector. Model: FX1 V Mechanical Line Leak Detector. Model: FX1 DV Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-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). Dispenser 1/2 Dispenser ID: 3 X❑ Dispenser Containment Sensor(s) Model: 794380-208 X 1 Dispenser Containment Sensor(s) Model: 794380-208 X❑ Shear Valve(s). -Xj Shear Valve(s) Dispenser Containment Float(s) and Chain(s). 7Dispenser Containment Float(s) and Chain(s). Dispenser ID: 4/5 Dispenser ID: 6 X❑ Dispenser Containment Sensors) Model: 794380-208 Dispenser Containment Sensor(s). Model:794380-208 Shear Valve(s). 71Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 7/8 Dispenser ID: 9/10 0 Dispenser Containment Sensors) Model: 794380-208 X Dispenser Containment Sensor(s). Model: 794380-208 ❑X Shear Valve(s). X Shear Velvets). ❑ 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): ❑ System set-up ❑ Alarm history report Technician Name (print): HEATH MCEVER Signature: 1--4� Certification No.: 3604 License. No.: Testing Company Name: Tanknology Phone No.: (800) 800-4633 Site Address: 8900 Shoal Creek, Bldg. 200 Austin, TX 78757 Date of Testing/Servicing: 05/03/2004 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification