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MONITORING SYSTEM CERTIFICATION 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 mast 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 appropriate boxes to indicates ificwent' serviced: Tank ID: 87 Tank M. 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 Surup!Trench Sensors} ModeL• 208 ®Piping Sump/Trench Sensm(s� Model: 208 ®Fill Sump Sensors} Model: 208 ®Fill Sump Seraar(s} Model- 208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ® Electronic Line leak Detector_ Model: $484 ®EIectronic Line Leak Detector. Model- 8484 ❑Tank Overfill!High-Level Sensor. Model- ❑Tank Overfill/High-Level Sensor. Model: ®Other(specify eguipmem type and model in Section E on Page 2). ®Other(specify equipment type and model in Section E on Page 2} Tank ID: Diesel Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor_ Model: ®Piping Sump/Trench Sensor(.} Model: 208 ❑Piping Sump!Trench Sensor(s� Model: ®Fill Sump Sensor(s)- Model: 208 ❑Fin Sonrp Sensors) Model: ?' ❑Mechanical line Leak Detector_ Model: [I Mechanical Line Leak Detector_ Model: r ®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 equrpmeol type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 ®Dispenser Cortainmer t gerrsor(%} Model- 208 ®Dispenser C d i...r*Sersar(.} Model: 208 ❑Shear Valve(s). ❑Shea Valves)_ ❑DispensiT Contaimaent Floats)and Chain(s)- ❑Dispenser Comaimnent Floats)and Chaia(s). Dispenser ID: 5/6 Dispenser ID 7/8 ®Dispenser Contaimnent Sensor(s). Model: 208 ®Dispenser Coutainrnetu Scussor(s)_ Model: 208 ❑Shea Valve(s). ❑Shear Valve(s} ❑Dispenser C<mtainment Float(.)and Chains} ❑Dispenses Contain—t Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors}. Model: ❑Dispenser eontainmerd Sensor(s� Model: ❑ Shear Valve(s). ❑Shear Valve(s)L ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Coutautment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at see L"UlLy. _V.--mens !qe _��,._.___ ___nnrsd in this document was inspected/serviced in accordance with the Auacnee ee ria..Cerntication is information(e_g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. reports,I have also attached a copy of the report;(check all?ham+appl;;:V C.•__ _-__ r _-_ ___-- Prhr,;_jpya Name Gavin Williams Signature: erdfication No.: ICC: 8016288-UT License.No.: CSLB:341375 Testing Company Name: APEC Phone No.:£2091 467.75 Testing Company Address: PO Box 55105 Stockton,CA 95205 Date of Testingr'' Page 1 of 3