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MONITO KING SYSTEM CERTIICATION 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 Facility Name: VALLEYPACIF/C CARDLOCK#152 Bld . No.: Site Address: 930 E. VICTOR RD City: LODI I Zip: 95240 Facility Contact Person: MIKE EL/ASON Contact Phone No.: 209) 948-9412 Make/Model of Monitoring System: /NOON TS2001 Date of Testing/Servicing: JUNE 29, 2006 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID:REGULAR Tank ID:_ Z In-Tank Gauging Probe. Model:MAG ❑In-Tank Gauging Probe. Model:_ Z Annular Space or Vault Sensor. Model:FLOAT ❑Annular Space or Vault Sensor. Model:_ Z Piping Sump/Trench Sensor(s). Model:FLOAT ❑Piping Sump/Trench Sensor(s). Model:_ ❑Fill Sump Sensor(s). Model:_ ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model:FXIV ❑Mechanical Line Leak Detector. Model:_ ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model:_ Z Tank Overfill/High-Level Sensor. Model:FLOAT ❑Tank Overfill/High-Level Sensor. Model:_ ❑Other(specify equipment a and model in Section E on Pae 2). ❑Other(specify equipment a and model in Section E on Pae 2). Tank ID:SUPER Tank ID:_ Z In-Tank Gauging Probe. Model:MAG ❑In-Tank Gauging Probe. Model:_ Z Annular Space or Vault Sensor. Model:FLOAT ❑Annular Space or Vault Sensor. Model:_ Z Piping Sump/Trench Sensor(s). Model:FLOAT ❑Piping Sump/Trench Sensor(s). Model:_ ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model:_ Z Mechanical Line Leak Detector. Model:FXIV ❑Mechanical Line Leak Detector. Model:_ ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model:_ Z Tank Overfill/High-Level Sensor. Model:FLOAT ❑Tank Overfill/High-Level Sensor. Model:_ ❑Other(specify equipment type and model in Section E on Pae 2). ❑Other(specify equipment a and model in Section E on Page 2). Dispenser ID: 11=2 Dispenser ID: 77=8 ❑Dispenser Containment Sensor(s). Model:_ [IDispenser Containment Sensor(s). Model:_ Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Floats and Chain (s). Z Dispenser Containment Float(s) and Chain(s). Dispenser ID:334 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: 55=6 Dispenser ID: ❑Dispenser Containment Sensor(s). Model:_ ElDispenser Containment Sensor(s). Model:_ Z Shear Valve(s). ❑Shear Valve(s). Z 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 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 ®Alarm history report Technician Name(print): ROBERT NE/MEYER Signature: Certification No: 06043717 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No: (707)446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testin Servicin JUNE 29, 2006 Page 1 of 3 Monitoring System Certification