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MONARING SYSTEM CERTIFIL,.TION 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: 99 Shell Bldg.No.: Site Address: 7700 Moreland Ct City: Stockton Zip: 95212 Facility Contact Person: Mr. Angle Contact Phone No.: ( ) Make/Model of Monitoring System: TLS-350R Date of Testing/Servicing: 9/8/2010 B. Inventory of Equipment Tested/Certified Check the ap2ropriate boxes to indicate 3pMiric equipment ins ected/sen iced: _ Tank ID: 87 Tank ID: 91 ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 303 ®Annular Space or Vault Sensor. Model: 303 ® Piping Sump/Trench Sensor(s). Model: 208/304 ®Piping Sump/Trench Sensor(s). Model: 208/304 ®Fill Sump Senwr(s). Model: 2081 304 N Fill Sump Sensor(s). Model: 2081304 �! ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: 8484 ®Electronic Line Leak Detector. Model: 8484 ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ®Other(specif)equipment h pe and model in Section E on Paas 2), ®Other(specify equipment npe and model in Section F on Page 2). Tank ID: Diesel Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: 303 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 208/304 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: 2081304 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: 8484 ❑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 F,on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 ®Dispenser Containment Sensor(s). Ivlodcl 2081 304 ® Dispenser Containment Sensor(s). Model: 208/304 ❑Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and ChaWls). Dispenser ID: 516 Dispenser ID: 718 ®Dispenser Containment Sensor(s). Model 2081304 ®Dispenser Containment Sensor(s). Model: 2081304 ❑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). 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 Gavin Williams Signature: ��— Certification No.: ICC: 8016288-UT License.No.: CSLB: 341375 Testing Company Name: APEC Phone No.:(209) 467-7573 Testing Company Address: PO Box 55105 Stockton, CA 95205 Date of Testing/Servicing: 9/8/2010 Page 1 of 3