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ONIT NG SYSTEM CETI CATION For Use By 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 equipment. 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: CRLLC#2705447 FB—1d g. No.: Site Address: 1469 E.HAMMER LANE Cit : STOCKTON I Zip: 95209 Facility Contact Person: ARMEN MKRTYTCH/AN Contact Phone No.: (925)884-080 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: JUL 19, 2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID:91 Tank ID:89 Z In-Tank Gauging Probe. Model:MAG Z In-Tank Gauging Probe. Model:MAG Z Annular Space or Vault Sensor. Model:409 Z Annular Space or Vault Sensor. Model:409 Z Piping Sump/Trench Sensor(s). Model:208 Z Piping Sump/Trench Sensor(s). Model:208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model:LD 2000 Z Mechanical Line Leak Detector. Model:FXIV ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model:FLOAT/FLAPPER Z Tank Overfill/High-Level Sensor. Model:FLOAT/FLAPPER ❑Other(specify e ui ment e and model in Section Eon Pa e 2). ❑ Other(speciLy a ui ment ty e and model in Section E on Pa e 2 . Tank ID:87 Tank ID:DIESEL Z In-Tank Gauging Probe. Model:MAG ®In-Tank Gauging Probe. Model:MAG Z Annular Space or Vault Sensor. Model:409 Z Annular Space or Vault Sensor. Model:409 Z Piping Sump/Trench Sensor(s). Model: 208 Z Piping Sump/Trench Sensor(s). Model:208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model:LD 2000 Z Mechanical Line Leak Detector. Model:LD 2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model:FLOAT/FLAPPER Z Tank Overfill/High-Level Sensor. Model:FLOAT/FLAPPER ❑Others eci equipment e and model in Section E on Pae 2). ❑Other(specify equipment e and model in Section E on Pae 2). Dispenser ID: 102 Dispenser ID:33=4 Z Dispenser Containment Sensor(s). Model:BEAUDREAU Z Dispenser Containment Sensor(s). Model:BEAUDREAU Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Floats and Chain (s). Z Dispenser Containment Floats and Chain (s). Dispenser ID:556 Dispenser ID: 7758 Z Dispenser Containment Sensor(s). Model:BEAUDREAU Z Dispenser Containment Sensor(s). Model:BEAUDREAU Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Floats and Chain (s). Z Dispenser Containment Floats and Chains . Dispenser ID:9-10 Dispenser ID: Z Dispenser Containment Sensor(s). Model:BEAUDREAU ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑Shear Valve(s). Z Dis enser Containment Floats and Chain(s). I ❑Dis enser Containment Floats and Chains . *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 the 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 Z Alarm history report _7Technician Name(print): MIKE LAWRENCE Si nature: Certification No:A26642 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707)446-6151 Address: 607 ELMIRA RD,PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: JUL 19,2010 Page 1 of 3 Monitoring System Certification