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�[�C E Ili V/NIORING SYSTEM CERT14ATION For Use By All Jurisdictions Within the State of California JUL 1 6 2009 Authority Cited.• Chapter 6 7, Health and Sa)r--IY Code, Chapter 16, Division 3, Title 23, Ca1iforna6MW1#T1"?1FALTS This form must be used to document testing and servicing Of monitoring equipment. A separate certification or Lepof`P&6611�a"O eac monitoring system control panel by the technician who performs the work- A copy of this form must be provided to the tank system owner/operatorh . 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: HAMMER LANE OIL Bldg. No.: Site Address: 3304 Hammer Lane Facility Contact Person: Mike Germ City: Stockton CA - Zip: 95206 Contact Phone No.: (209) 478-9293 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 612212009 B. Inventory of Equipment Tested/Certified Check thea l!==riate boxes to indicate seecific Equigment insLected/serviced. Tank ID: TI: 87 Tank ED: T2: 91 0 In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. 0 In -Tank Gauging Probe. Model: Model: 0 Piping Sump / Trench Sensor(s). Model: 794380-208 ®Annular Space or Vault Sensor. Model: 794390-420 split tank 0 Fill Sump Sensor(s), Model: 0 Piping Sump / Trench Sensor(s). Model: 794380-208 0 Mechanical Line Leak Detector, Model: FE Petro STP --MLD 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. 0 Electronic Line Leak Detector. Model: Model: FE Petro STP -MLD 0 Electronic Line Leak Detector. 0 Tank Overfill / High -Level Sensor. Model: 0 Other (specify 0 Other (specify equipment type and model in Section E Page Model: 0 Tank Overfill / High -Level Sensor. Model: on 2). ❑ Other (specify equipment type and model in Section E on Page 2). 1 T3: Diesel E-Nmas� rTankID: [31 T, — [I In -Tank Gauging Probe. Model: Tank ID: El In -Tank Gauging Probe. Annular Spa nnular Space or Vault Sensor. Model: 794390-420❑ Piping Sump / Trench Sensor(s). Model: Model: Annular Space or Vault Sensor. Model: 794380-208❑ ❑ Fill Sump Sensor(s). Piping Sump /Trench Sensor(s). Model: Model: Mechanical Line Leak Detector. Model: RJ FX I DV El Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. 0 Electronic Line Leak Detector. Model: Model: 0 Electronic Line Leak Detector. El Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment type and model in Section E Page Model: El Tank Overfill / High -Level Sensor. Model: Is! ................... j 1 M" on 2). El Other (specify equipment type and model in Section E on Page 2). 1) Dispenser ED: I & 2 El Dispenser Containment Sensor(s). Model: Dispenser ID: 3 & 4 Shear Valve(s). 0 Dispenser Containment Sensor(s). Model: Dispenser Containment Float(s) and Chain(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5 & 6 Dispenser Containment Sensor(s). Model: Dispenser ED: 7 & 8 Shear Valve(s). 0 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Float(s) and Chain(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: El Dispenser Containment Sensor(s). Model: Dispenser ID: n Dispenser Containment Sensor(s). Model: [I Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). 0 Shear Valve(s). *If El Dispenser Containment Float(s) and Chain(s). the facility contains more tanks or dispensers, copy this form. Include informatinn fpr p v�_, tt, A A: -, __j ••••••• .........op,wiKi at ulizidC1111y. 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): System set-up ®Alarm history re ort n I Technician Name (print): Robert Barnhart Signature: Certification No.: B35969 License. NO Testing Company Name: Reliable Petroleum Service Inc. Phone No.: (209) 845..s586 Testing Company Address: 521 Branding Iron Street, Oakland CA 95361 Date of Testing/Servicing: 6/22/2009 Page I of 4 UN -036 —1/4 www.unidocs.org Rev. 01/17"