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MONIT*UNG SYSTEM CERTIFATION 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 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. A. General Information FacilityName: SHANE B DA VE'S Bldg.No.: Site Address: 3550 HWY 99 City: STOCKTON Zip: 95215 Facility Contact Person: Contact Phone No.: (209)948-9412 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: 3/2112012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced. Tank ID: 87 Tank ID: RED DIESEL ®In-Tank Gauging Probe. Model: MAG ®In-Tank Gauging Probe. Model: MAG ®Annular Space or Vault Sensor. Model: 420 ®Annular Space or Vault Sensor. Model: 420 ®Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: LD 2000 ®Mechanical Line Leak Detector. Model: LD 2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: E Tank Overfill/High-Level Sensor, Model: FLOAT I FLAPPER ®Tank Overfill/High-Level Sensor. Model: FLOAT I FLAPPER El Other(specify equipment type and model in Section Eon 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 tD: 1/2 Dispenser tD: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ❑Shear Valve(s). ®Dispenser Containment Floats)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). Dispenser tD: 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,1 have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name(print): MIKE LA WRENCE Signature: Certification No.: A26642 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: 3/21/2012 Page 1 of 4 UN-036— www.unidocs.org Rev.01/17/08