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2098253893 ENGINEERING DEPT. 09,ifiL.54 a.m. 09-10-2010 19/21 MONITOR SYSTE CE TIFICATIO For Use y 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 equf ment. If more than one monitoring system control panel is installed at the facility,a separate certification or report must be prepared for each monitoring system control p�hei by the technician who performs the work. A copy of this form must be provided to the tank r"tem 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. I ueneral Information Facility Name: KAISER MANTECA City: MANTECA CA Zip:95337 Site Address: 1777 W YOSEMITE AVE Contact Phone No: 825-3460 Date of Testing/Service: 08/13/2010 Facility Contact Person: ENGINEERING MANAGER Make/Model of Monitoring System:OWENS CORNING Work Order Number. 2276292 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: T1-DSL Tank ID: 1n-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model S 10B Annular Space or Vault Sensor. Model: X Piping Sumprfrench Sensor(s). Model: ` S-3 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. Madel: X Tank Overfill/High-Level Sensor, Model: FLAPPER Tank Overflll/High-Level Sensor. Model: Other(specify a)ufpment type and m6del in Section E on page 2). Other(specify equipment type and model in Section E on page 2). ank I : Tank 1 : In-Tank Gauging Probe. 11311odel: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sumprrrench 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: Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). 771 Other(specify equipment type and model in Section E on page 2). Dispenser Dispenser 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 Chafn(s). Dispenser ID: Dispenser ID: ®Dispenser Containment Sensor(s) Model: / Dispenser Containment Sensor(s). Modes: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID'. Dispenser Containment Sensor(s) Mpdel: Dispenser Containment Sensor(s). Model: Shear Valve(s). t,' Shear Vaive(s). Dispenser Containment Float(s)and Chain(s). Ll 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 r „1 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 th7layout 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 ®Alarm history report Technician Name(print): KELVIN CRUZ Signature: Certification No.: License.No.: 743160(Ciass'A'General Enginering Contractor License) ?4sting Company Name:Tanknology Phone No.: (800)800-4633 Address: 11000 N.MoPac Expressway,suite 500,Austin,TX 78759 Date of Testing/Servicing: 08/13/2010 1 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08