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MONITfLNG SYSTEM CERTIFATION 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: SBC Site Address: 10 E. 12TH STREET Facility Contact Person: KATHY HALLIGAN GEO PAR # UE -058 CLLC Code: TRACCAI 1 City: TRACY Contact Phone No Zip: 209-474-4514 Make/Model of Monitoring System: VEEDER ROOT TLS -350 Date of Testing/Service: 8/5/04 B. Inventory of Equipment Tested/Certified er_.. ..* • of P(1 �CPYVIPP�• Check the appropriate Dozes to ,uuwcatr vt.IAM _ . every --- Tank ID: 1232 Tank ID: ❑In -Tank Gauging Probe: Model: ®In -Tank Gauging Probe: Model: 847390-107 ®Annular Space or Vault Sensor: Model: 794390-420 ❑Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensor (s): Model: 794380-352 ❑Piping Sump/Trench Sensor (s): Model: ®Fill Sump Sensor (s): Model: 794380-352 ❑Fill Sump Sensor (s): Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: []Electronic Line Leak Detector Model: ®Tank Overfill/High-level Sensor: Model: 790091-001 ❑Tank Overfill/High-level Sensor: Model: ®Other, Specify a quip. type and model in Section E on Page 2 ❑Other, Specify equip. a and model in Section E on Pae 2 Tank ID: 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 (s): Model: ❑Piping Sump/Trench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: []Fill Sump Sensor (s): Model: []Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: in Section E on Page 2 ❑Tank Overfill/High-level Sensor: ❑Other, Specify a ui a and model Model: in Section E on Page 2 []Other, Specify e ui a and model Dispenser ID: ❑Dispenser Containment Sensor(s): Model: Dispenser ID: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). Containment Float(s) and Chain(s) ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) ❑Dis enser Dispenser ID: ❑Dispenser Containment Sensor(s): Model: Dispenser ID: []Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) Dispenser ID: ❑Dispenser Containment Sensor(s): Model: Dispenser ID: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). Containment Float(s) and Chain(s) ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s [:]Dispenser c__ _1.....d .7:.. 4f fha f6,;1ity *If the facility contains more tanks or dispensers, copy this form. include miu,n,auun iu1 very .— a..0 .. ....1. 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): _ gg System set-up ® Alarm history report Technician Name (Print): BRIAN GONZALES Signature. Certification No.: 4812 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222