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MONITANG SYSTEM CERTIffATION MAR 1 7 2010 For Use By All Jurisdictions Within the State of California DD�, Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California CcWpV)��RWUW HEALTH This form must be used to document testing and servicing of monitoring equipment. A separate certifical ni oorrlT/sreportRmust b 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: SHANE&DAVE S Site Address: 3550 HWY99 Ci : STOCKTON I Zip: 95215 Facility Contact Person: MIKE ELIASON Contact Phone No.: (209)948-9412 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: MAR 12,2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ected/serviced: Tank ID:87 Tank ID:RED DIESEL Z In-Tank Gauging Probe. Model:MAG Z In-Tank Gauging Probe. Model:MAG Z Annular Space or Vault Sensor. Model:420 Z Annular Space or Vault Sensor. Model:420 Z Piping Sump/Trench Sensor(s). Model:208 Z Piping Sump/Trench Sensor(s). Model:208 ❑Fill Sump Sensor(s). Model:_ ❑Fill Sump Sensor(s). Model:_ Z Mechanical Line Leak Detector. Model:STP-MLD Z Mechanical Line Leak Detector. Model:LD 2000 ❑Electronic Line Leak Detector. Model:_ ❑ Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model:FLAPPER/FLOAT Z Tank Overfill/High-Level Sensor. Model:FLAPPER/FLOAT ❑Other(specify equipment a and model in Section E on Pae 2). ❑ Other(specify equipment a and model in Section E on Pa e2). 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(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 a ui ment=e and model in Section E on Pae 2). ❑Other(sl)ecifv equipment a and model in Section E on Pae 2). Dispenser ID: 11=2 Dispenser ID:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Dispenser Containment Sensor(s). Model:_ Z Shear Valve(s). ❑Shear Valve(s). Z Dispenser Containment Floats and Chain (s). ❑Dispenser Containment Floats 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 Floats and Chain (s). ❑Dispenser Containment Floats and Chain (s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Shear Valve(s). ❑Shear Valve(s). ❑Dis enser Containment Floats and Chain (s). ❑Dispenser Containment Floats 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 the Certification is information(e.g.manufacturers' checklists)necessary to verify that this information is correct and a 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): ® System set-up Z Alarm history report Technician Name(print): MIKE LAWRENCE Signature: - Certification No:A26642 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707)446.6151 Address: 607 ELMIRA RD,PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: I MAR 12, 2010 Page I of 3 Monitoring System Certification