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MONITAING 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 Signature: Facility Name: FLAME LIQUOR - MINI MART Bld . No.: Site Address: 1301 W. KETTLEMAN LANE City: LODI I Zip: 95242 Facility Contact Person: PETE GRAFF/GNA Make/Model of Monitoring System: G/LBARCO EMC Contact Phone No.: (209) 334-3233 I Date of Testing/Servicing: Nov 8, 2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snecifie equipment inennntnd �curvinnA• u ine mcuity 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): Z System set-up Z Alarm history report Technician Name (print): ROBERT NE/MEYER Signature: Certification No: 000-19-8246 D: REGULAR Testin Com any Name: TANK-TEK ENVIRONMENTAL CORPORATION Tank ID: DIESEL I Phone No: (707) 446-6151 ank Gauging Probe. FNIAnnular Model: MAG ® In -Tank Gauging Probe. Model: MAG Space or Vault Sensor. Model: 420Z Annular Space or Vault Sensor. Model: 420 ng Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD2000 Z Mechanical Line Leak Detector. Model: FXIV ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLOAT Z Tank Overfill / High -Level Sensor. Model: FLOAT ❑ Other Ls2ecify equipment e and model in Section E on Pae 2). ❑ Other �specif X. equipment e 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: 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: LD2000 ❑ 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: ❑ OthELspecify equipment a and model in Section E on Pa e 2). ❑ Others eci equipment e and model in Section E on Pae 2). Dispenser ID: 11-22 Dispenser ID: 77-88 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dis enser Containment Floats and Chain(s). Z Dis enser Containment Floats and Chain(s). Dispenser ID: 33=4 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). El Shear s). Z Dis enser Containment Floats and Chain(s). ❑Dis Dispenser C er Containment Floats and Chains . Dispenser ID: 5_6 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 Chains . u ine mcuity 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): Z System set-up Z Alarm history report Technician Name (print): ROBERT NE/MEYER Signature: Certification No: 000-19-8246 License: 803705 Testin Com any Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707) 446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testing/ServicinE. I NOV 8, 2007 Page 1 of 3 Monitoring System Certification