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%' gal RECE EU MONITORING SYSTEM CERTIFICATIOI4lAR I 1 2008 For Use and All Jurisdictions Within the State 3,California orIP9 C n' Authority Cited.-Chapter 6.7,Health and Safety Code; Chapter 16, a tae 3, Title 23, Calf oNVI h1 T This form most be used to document testing and servicing of monitoring equipment.-If-mono.tham- na4nonitefirlg-system-aomroF-{tana4-ie-tnstaged at the facility,a—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..-htstmotions-ere-printed-ort-the-baek-cfthis-page. A. General Information FacilityName: Country Market Place Bldg. No.: Site Address: 1789 W. Charter Ave City: Stockton Zip: 95206 Facility Contact Person: HarjinderContact Phone No.: (209) 933-1789 Make/Model of Monitoring System: Veeder Root TLS350 Date of Testing/Servicing: 3-12-08 B. Inventory of Equipment Tested/Certified Cheek the appropriate bozn to Indicate s ciflc a ul ment ins Med/servittde: Tank ID: 87 Tank ID: 91 X In-Tank Gauging Probe. Model: 847390-107 X In-Tank Gauging Probe. Model: 847390-107 X Annular Space or Vault Senior. Model: 794390-420 X Annular Space or Vault Sensor. Model: 794390-420 X Piping Sump/Trench Sensor(s). Model: 794380-208 X Piping Sump/Trench Screor(s). Model: 794380-208 ❑Fill Sump semor(s). Model: ❑Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: 99LD2000 X Mechanical Line Leak Detector. Model: 116-035 ❑Electronic Line Leak Detector. Madel: ❑Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: 790091-001 X Tank Overfill/High-Level Senior. Model: 790091-001 ❑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: ❑Piping Sump/Trench Sensor e). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Semor(s). Model: ❑Fill Sump Semor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Demeter. Model ❑Electronic Line Leak Defector. 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 ID: 18,2 Dispenser ID: 3&4 X Dispenser Confa rment Sensor(,). Model: PA02595000011 X Dispenser Containment Sensor(s). Model: PA02595000011 X Sheer Velve(s). X Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(,)and Chain(s). Dispenser ID: 58,6 Dispenser ID: 78,8 X Dispenser Containment Sensor(s). Modcl: PA02595000011 X Dispenser Containment Sensor(s). Model: PA02595MO011 X Shear Valve(s). X Shear Velve(s). ❑Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s} Dispenser ID: 9&10 Dispenser ID: 11&12 X Dispenser Containment Semor(s). Model: PA02595000011 X Dispenser Containment Sensor(,). Model: PA0269600001l X Shur Valve(s). X Sheen Valve(s). ❑Dispenser Containment Floats)and Chain(,). ❑Dispenser Containment Flost(s)and Chain(,). -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-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): m set-up X Alarm history report Technician Name James A.Williams Signature:_ Certification A32464 License 433159 Testing Company Name: BZ Service Station Maintenance Phone No.:(916) 371-2380 Site Address: 630 Houston Street West Sacramento, CA 95691 Date of Testing/Servicing: 3-12-08 Page 1 of 3