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MONIP&ING SYSTEM CERTIWATION 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: BOYETT PETROLEUM#5—MANTECA EXPRESS =Bldg. No.: Site Address:419 S MAIN STREET City: MANTECA I Zip: 95363 Facility Contact Person: BOBBY MANGAT Contact Phone No.: (209)239-7978 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: APRIL 12, 2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: SUPER Tank ID:DIESEL Z In-Tank Gauging Probe. Model:MAG Z In-Tank Gauging Probe. Model:MAG Z Annular Space or Vault Sensor. Model:420 Z Annular Space or Vault Sensor. Model:420 Z Piping Sump/Trench Sensor(s). Model:208 ®Piping Sump/Trench Sensor(s). Model:208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model:LD 2000 Z Mechanical Line Leak Detector. Model:FX10 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model:FLOAT Z Tank Overfill/High-Level Sensor. Model:FLOAT ❑Other(specify equipment e and model in Section E on Pa e 2). ❑Other(specify equipment t, e and model in Section E on Pae 2). Tank ID:REGULAR Tank ID: Z In-Tank Gauging Probe. Model:MAG ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model:420 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model:208 ❑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 e and model in Section E on Page 2). ❑Other(specify a ui ment type and model in Section E on Page 2). Dispenser ID: 11-22 Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser 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). Dispenser ID: 33-44 Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑Shear Valve(s). Z Dis enser Containment Floats and Chain(s). ❑Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑ Dis enser Containment Floats 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 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 NEIMEYER Signature: Certification No: 000-19-8246 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 Testing/Servicing: APRIL 12, 2007 Page 1 of 3 Monitoring System Certification