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MONITOF"NG SYSTEM CERTIFt" ATION This form must be used to document testing a~servicing of monitoring equipment. Technicia�fiaL, prepare a separate certification or report for each monitoring system control panel. 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. General Information SET Job#: 019238 Facility Name: _ _ Yellow Transportation TCY Bldg.No.: Site Address: 1535 E.Pescadero Ave. City:_ Tracy State: CA Zip: 95376 Facility Contact Person:___ Richard Smith Contact Phone No.: 209-833-1300 Make/Model of Monitoring System: Veeder Root TLS 25013:2 Date of Testing/Servicing: 3/18/2004 Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate a ui ment inspected and/or serviced: Tank ID: TCY5 Gear Oil 6K Tank ID: TCY6 Antifreeze 61K ®In-Tank Gauging Probe. Model: Mau 1 N In-Tank Gauging Probe. Model: _ _ Mag 1 ®Annular Space or Vault Sensor. Model: 407 ®Annular Space or Vault Sensor. Model: 302 ®Piping Sump/Trench Sensor(s). Model: _ 208 _ ®Piping Sump/Trench Sensor(s). Model: _ 206 []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: OPW 6150 ®Tank Overfill/High-Level Sensor. Model: oPW 6150 El Other ❑Other Tank ID: TCY7 Waste Oil 4K Tank ID: TCYSA N In-Tank Gauging Probe. Model Mag 1 ❑In-Tank Gauging Probe. Mo �� p-�I� �� NAnnular Space or Vault Sensor. Model: . 302 _ ❑Annular Space or Vault Sensor. Moe �w IN Piping Sump/Trench Sensor(s). Model: _ 208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: _ _ --__ ❑Fill Sump Sensor(s). Model: R0 5 2004 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. MoCel tONN E TFfEAUH NTank Overfill/High-Level Sensor. Model: 0121011111151) ❑Tank Overfill/High-Level Sensor. ModelPEKMI I/SEHVIULS- ❑Other ❑Other Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: - ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)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 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 Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Include information for every tank and dispenser at the facility. Certification-t 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): N System set-up ® Alarm history Technician Name(print): Roy Walker Signature: /� _ Certification No.: 4307 License.No.: 814027 Testing Company Name: Shirley Environmental Testing Phone No.: (626)444-7447 Site Address: 1928 Tyler Avenue Suite K South EI Monte,CA 91733 Date of Testing/Servicing. 3/18/2004 - Monitoring System Certification Page I of 4 3101