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MONITORING SYSTEM CERTIFICATION Fk e By All Jurisdictions Within the State of Califomia Authority Cited:Chapter 6.7,Heanci Safety Code;Chapter 16,Division 3 Title 23, C�n4mia 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 ownedopemtor 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: CIRCLE K 2701205 City: LATHROP CA Zip:95330 Site Address: 16470 CAMBRIDGE Contact Phone No: 8584116 @ LOUISE Date of Testing/Service: 10/14/2010 Facility Contact Person: MANAGER-ROBERT Make/Model of Monitoring System:VR-TLS350 Work Order Number: 2277281 S.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: T1-REG Tank ID: T2-PRE -Xi In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 303 Annular Space or Vault Sensor. Model: 303 71 Piping Sumprrmnch Sensor(s). Model: 208208 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FX1 V 1X1 Mechanical Line Leak Detector. Model: MLD Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: FLAPPER Tank Ovwfill/High-Level Sensor. Model: FLAPPER 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: TanklD: In-Tank Gauging Probe. Model: DIn-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sumprrrench Sensor(s). Model: Piping Sumprrmnch 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 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: 3/4 7 Dispenser Containment Sensor(s) Model: Dispenser Containment Semsor(s) Model: FX Shear Valve(s). X Shear Valve(s) EDispenser Containment Float(s)and Chain(s). X Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). D 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 cerfify that the equipment identified in this document was inspected/serviced in accordancewith 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 X❑Alarm history report Technician Name(print): KELVIN CRUZ Signature: Certification No.: A22519 License.No.: 743160(Class'A'General Enginering Contractor License) Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 11000 N.MoPac Expressway,suite 500,Austin,TX 78759 Date of Testing/Servicing: 10/14/2010 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08