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MONITSUNG SYSTEM CERTIFI4TION 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 toI �I_op'7tor. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of to =v l V A. General Information APR 1 7 2008 Facility Name: KJS ENTERPRISE Bldg.No.: Site Address: 1100 S. Main St. City: Manteca Ca. Facility Contact Person: Jessie Chadda Contact Phone No.: (209) 825-r� *"` Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 3/27/2008 B. Inventory of Equipment Tested/Certified Check the aggropriate boxes to indicates ific a ui ment inspected/serviced: Tank tD: T1: Unleaded Tank ID: T2: Premium M In-Tank Gauging Probe. Model: 8473-90-109 M In-Tank Gauging Probe. Model: 847390-109 M Annular Space or Vault Sensor. Model: 794390-409 ®Annular Space or Vault Sensor. Model: 794390-409 M Piping Sump/Trench Sensor(s). Model: 794380-323 ®Piping Sump/Trench Sensor(s). Model: 794380-323 M Fill Sump Sensor(s). Model: 794380-323 ®Fill Sump Sensor(s). Model: 794380-323 M Mechanical Line Leak Detector. Model: VMI 99 LD 2000 M Mechanical Line Leak Detector. Model: FE Petro STP-MLD ❑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). Tank ID: T3: Plus Tank ID: M In-Tank Gauging Probe. Model: 8473-90-109 ❑In-Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: 794390409 ❑Annular Space or Vault Sensor. Model: M Piping Sump/Trench Sensor(s). Model: 794380-323 ❑Piping Sump/Trench Sensor(s). Model: M Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: VMI 99LD 2000 ❑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 ID: 1 +4 Dispenser ID: 2+5 M Dispenser Containment Sensor(s). Model: 794380-323 ®Dispenser Containment Sensor(s). Model: 794380-323 M Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3+6 Dispenser ID: 7+ 12 M Dispenser Containment Sensor(s). Model: 794380-323 M Dispenser Containment Sensor(s). Model: 794380-323 M Shear Valve(s). M Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 8+ 11 Dispenser ID: 9+ 10 M Dispenser Containment Sensor(s). Model: 794380-323 ®Dispenser Containment Sensor(s). Model: 794380-323 M Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)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): Guadalupe Sanchez Signature- Certification No.: A30138 License.No.: 883706 Testing Company Name: RELIABLE PETROLEUM SERVICES INC. Phone No.:(209) 845-8586 Testing Company Address: 521 Branding Iron St. Oakdale Ca.95361 Date of Testing/Servicing: 3/27/2008 Page 1 of 3 Rev(2/08)