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ONIT NG SYSTEM CETIFI TION se By All Jurisdictions Within the State of Califomi Authority Cited., Chapter 6.7, Health and Safety Code; Chapter 16, Division 3 Title 23, California Code of Regulations This form mus=a d to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, a separate certification ormust 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: CONOCO PHILLIPS #2611194 Site Address: 2375 TRACY BLVD Facility Contact Person: MANAGER Make/Model of Monitoring System:TLS350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced City: TRACY CA Zip: 95376 Contact Phone No: 835-5358 Date of Testing/Service: 04/11/2005 Work Order Number: 2235641 Tank ID: 1 Tank ID: 2 R In -Tank Gauging Probe. Model: MAG X In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: 409 )( Piping Sump/Trench Sensor(s). Model: 208 X1 Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FE Mechanical Line Leak Detector. Model: LD2000 Electronic Line Leak Detector. Model: 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 E on page 2). TanklD: J TanklD: )( In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: )( Annular Space or Vault Sensor. Model: 409 71 Annular Space or Vault Sensor. Model: 409 X Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FE Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 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 E on page 2). Dispenser : 1/2 Dispenser ID: 3/4 7 Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: X❑ Shear Valve(s).X Shear Valve(s) QX Dispenser Containment Float(s) and Chain(s). -X-1 Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 F]Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: X❑ Shear Valve(s). 71 Shear Valve(s). X Dispenser Containment Float(s) 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the (Check all that apply): � System set-up XQ Alarm history report Technician Name (print): TONY DUNCAN Certification No.: 8125 Signature: _ License. No.: Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 04/11/2005 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01