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ONIT NG SYSTEM CERTIFIC ION e By All Jurisdictions Within the State of Californialliiiiiiiiii Authority Cited. Chapter 6.7, He , and Safety Code, Chapter 16, Division 3 Title 23, C rnia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. 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 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: TEICHERT CONSTRUCTION Site Address: 120 FRANK WEST CIRCLE Facility Contact Person: GEORGE Make/Model of Monitoring System:TLS-350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced City: STOCKTON Contact Phone No: 386-3716 Date of Testing/Service: 03/02/2007 Work Order Number: 2247586 CA Zip: 95206 Tank ID: DIESEL Tank ID: 87 X In -Tank Gauging Probe. Model: MAG X In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 407 Annular Space or Vault Sensor. Model: 407 X Piping Sumplfrench Sensor(s). Model: 208 Piping Sumpfrrench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Hx Model: LD2000 X Mechanical Line Leak Detector. Model: LD2000 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: MAG 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). Tank ID: WAS I L OTC Tank ID: 71 In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 407 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: -Xj Fill Sump Sensor(s). Model: 208 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: MAG 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 X❑ Dispenser Containment Sensor(s) Model: 208 --X-j Dispenser Containment Sensor(s) Model: 208 X❑ Shear Valve(s). X Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s). 7 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser lD: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: F]Shear Valve(s). Shear Valve(s). ElDispenser 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 X❑ Alarm history report 'jp, Technician Name (print): DENNIS RUE Signature: Certification No.: 006-05-1510 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: 03/02/2007 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01