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MONIARING SYSTEM CERTIFIOATIO For Use By All Jurisdictions Within the State of California Authoi ity Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California CAKf 0*a& & This form mu it be used to document testing and servicing of monitoring equipment.A sedate certificat[WJjFlib6dEt ksttkd*i ared for each mon toring system control tianel by the technician who performs the work. A copy of this form tank system owne operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test d tte. A. Generi IInformation Facility Nam :Systems Transport Bldg.No.: Shop Site Address: 707 E.Roth Road City: French Camp Zip 95231 Facility Contet Person: Steve Tucker Contact Phone No.: (209)983-8062 Make/Model of Monitoring System:Veeder-Root TLS-300C Date of Testing/Servicing: May 30,2008 B. Invent ry of Equipment Tested/Certified Check the amirmariate boxes to indicatespecific a ui ment inspected/serviced: FAnnurlar # DIESEL Tank ID: G ging Probe. Model: V/R Mal-Probe U In-Tank Gauging Probe. Model: S ace or Vault Sensor. Model: 794390-407 U Annular Space or Vault Sensor. Model: u p/Trench Sensor(s). Model: 794380-208 U Piping Sump/Trench Sensor(s), Model: U Fill Sump ensor(s). Model: N./A U Fill Sump Sensor(s). Model: (x)Mechanical Line Leak Detector. Model: VMI U Mechanical Line Leak Detector. Model: U Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Model: U Tank Overfill/High-Level Sensor. Model: U Tank Overfill/High-Level Sensor. Model: U Other(spec'ifv equipment a and model in Section E on Pae 2). U Other(specify equipment type and model in Section E on Page 2). Tank ID: #2 Tank ID: ( )In-Tank G uging Probe. Model: U In-Tank Gauging Probe. Model: Annular Srace or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sun ip/Trench Seasons). Model: U Piping Sump/Trench Sensor(s). Model: U Fill SumpSensor(s). Model: U Fill Sump Sensor(s). Model: U Mechanica Line Leak Detector. Model: U Mechanical Line Leak Detector. Model: U Electronic ine Leak Detector. Model: U Electronic Line Leak Detector. Model: U Tank Overfill/High-Level Sensor. Model: U Tank Overfill/High-Level Sensor. Model: U Other(specify equipment type and model in Section E on Page 2). U Other(specify equipment a and model in Section E on Pae 22. Dispenser IDqq SATELLITE#1 L-3 Dispenser ID: (x)Dispenser Containment Sensor(s). Model: 794380-208 U Dispenser Containment Sensor(s). Model: Shear Valve(s). U Shear Valve(s). ( Dis enser Containment Floats and Chain(s) U Dispense Containment Floats and Chains . Dispenser ID: MAIN DISPENSER L-4 Dispenser ID: Dispenser Containment Sensor(s). Model: 794380-208 U Dispenser Containment Sensor(s). Model: Shear Valvc(s). U Shear Valve(s). U Dispenser Containment Floats and Chain(s). U Dispenser Containment Float(s)and Chain(s). Dispenser ID!, SATELLITE 92 L-5 Dispenser ID: �B Dispenser Containment Sensor(s). Model: 794380-208 U Dispenser Containment Sensor(s). Model: Shear Valve(s). U Shear Valve(s). UqDis enser ontainment Floats and Chain's . CJ Dispenser Containment Floats)and Chain(s). *If the facili contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility C. Certif cation -1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelins. Attached to this Certification is information (e.g, manufacturers' checklists) necessary to verify that this information is correct nd a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attachec a copy of the report;(check all that apply): ( )System set-up ( )Alarm history report Technician Name(print): Eric Molgaard Signature: Eric NO@aard Certification No.: ICC 5250200-UT,Veeder-Root A27995&VMI 1278 and 1277 License No.: 309105 Testing Company Name:STOCKTON SERVICE STATION EQUIPMENT CO. INC. Phone No 209-464-8333 Site Addres : 707 E.Roth Road, French Camp,CA Date of Testing/Servicing: May 30,2008 Page 1 of 03101