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ONI NG SYSTEM CERTIF TION Use By All Jurisdictions Within the State of Califo Authority Cited:Chapter 6.7, alth and Safety Code;Chapter 16,Division 3 Title 23, alifomia 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: USA 835 City: STOCKTON CA Zip:95207 Site Address: 2705 COUNTRY CLUB BLVD Contact Phone No: 465-4756 Date of Testing/Service: 04/28/2004 Facility Contact Person: ROY Make/Model of Monitoring System:VEEDER-ROOT Work Order Number: 2230837 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: DIESEL Tank ID: PREMIUM X In-Tank Gauging Probe. Model: MAG-1 X In-Tank Gauging Probe. Model: MAG-1 X Annular Space or Vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. Model: 794390-420 )( Piping Sump/Trench Sensor(s). Model: 794380-208 Piping Sumpfrrench Sensor(s). Model: 794380-208 X Fill Sump Sensor(s). Model: 794380-208 794380-208 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LD2000 FXIV 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). Tank ID: KLU-UNL TanklD: R1 In-Tank Gauging Probe. Model: MAG-1 In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. Model: X Piping Sumprrrench Sensor(s). Model: 794380-208 Piping Sumpfrrench Sensor(s). Model: X Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FX1V 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: Q Shear Valve(s). -X-1 Shear Valve(s) QDispenser Containment Float(s)and Chain(s). X Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser lD: 7/8 FiDispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: X❑ Shear Valve(s). Shear Valve(s). X Dispenser Containment Float(s)and Chain(s). 11 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: ® Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). E] 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 ®Alarm history report Technician Name(print): HEATH MCEVER Signature: Certification No.: 3604 License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8900 Shoal Creek,Bldg.200 Austin,TX 78757 Date of Testing/Servicing: 04/28/2004 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01