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%W 114! MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within 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 se rate certification or report must be Pmallred for each monitoring system control stechnician whq rfomts the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator m114=* �opy of lid s,fgtm*the local agency regulating UST systems within 30 days of test date. Instructions are printed on the back of this page. OCT 2 u 2007 A. General Information ENVIRON(ti1CN` IiEr,iT�i FacilityName: Country Market Place PFRA411314gxq;, Site Address: 1789 W. Charter Ave City: Stockton Zip: 95206 Facility Contact Person: Halinder Contact Phone No.: (209) 933-1789 Make/Model of Monitoring System: Veeder Root TLS350 Date of Testing/Servicing: 9447 B. Inventory of Equipment Tested/Certified Checkthe as nate boxes to lndicate s ecillc v ui ment Inspected/serviced: 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 Sensor. Model: 794390420 X Annular Spam or Vault Sensor. Model: 794390420 X Piping Sump/Trench Semor(s). Model: 794380-208 X Piping Sump/Trench Sensor(s). Madel: 794380-208 ❑Fill Sump Semor(s). Model: ❑Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: 99L02000 X Mechanical Line Leak Detector. Model: 118-035 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: 790091-001 X Tank Overfill/High-Level Sensor. 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 Spam or Vault Sensor. Model: ❑Piping Sump/Trench Sen&or(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 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: 1&2 Dispenser ID: 3&4 X Dispenser Containment Sensor(s). Model: PA02595000011 X Dispenser Containment Sensors). Model: PA02595000011 X Shear Valve(s). X She.Valve(s). ❑Dispenser Containment Float(&)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&G X Dispenser Containment Sensor(s). Model: PA02595000011 X Dispenser Containment Semor(s). Model: PA02595000011 X Shear Valve(s). X She.Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: 911410 Dispenser ID: 11&12 X Dispenser Containment Sensor(s). Model: PA02595000011 X Dispenser Containment Sensor(s). Model: PA02595000011 X Shear Valve(a). X She.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 e equipmer}tr-Ne ny equipment capable of generating such reports,I have also attached a copy of the report; (check all that apply): X.System se up X Alarm history report Technician Name James A. Williams Signature: Certification No. A32464 License No. 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: 9-4-07 Page 1 of 3