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MON116UNG SYSTEM CERTIFIMTION RECEIVED 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. A separate certification or report must liApreRoa�edt`o 014 h monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the t hOR �C�(Q The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test dat HEALTH IV DEPARTMENT�, HEALTH DEPARTMENT A. General Information Facility Name: SHANE 8 DAVE'S Bldg.No.: Site Address: 3550 HWY 99 City: STOCKTON 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: 411/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecifre a ui ment inspected/serviced: Tank ID: 87 Tank ID: RED DYE DIESEL E In-Tank Gauging Probe. Model: MAG E In-Tank Gauging Probe. Model: MAG E Annular Space or Vault Sensor. Model: 420 E Annular Space or Vault Sensor. Model: 420 E Piping Sump/Trench Sensor(s). Model: 208 E Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: MLD STP ®Mechanical Line Leak Detector. Model: LD2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: FLAPPER ®Tank Overfill/High-Level Sensor. Madel: 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: 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 equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser D): 1/2 Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: E Shear Valve(s). ❑Shear Valve(s). E 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 Valm(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). ❑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 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 ®Alarm history report Technician Name(print): RICHARD THOMAS Signature: ?--a.V -� Certification No.: B34022 License.No.: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No.: (707)446.6151 Testing Company Address: 607 ELMIRA ROAD,PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: 4/112014 Page 1 of 4 UN-036— www.unidocs.org Rev.01/17/08