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'' '. SYSTEM • ?, 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 Signature: Facility Name: CRLLC #2705447 Bldg. No.: Site Address: 1469 E. HAMMER LANE City: STOCKTON I Zip: 95210 Facility Contact Person: CHUCK SOFT/CH Contact Phone No.: (253) 437-5980 Make/Model of Monitoring System: VEEDER-ROOT TLS -350 I Date of Testing/Servicing: AUG 5, 2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 91 Signature: Tank ID: 89 Certification No: A26642 ® In -Tank Gauging Probe. Model: MAG Z In -Tank Gauging Probe. Model: MAG ® 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 Sum Sensor(s). ❑ pModel: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD 2000 Z Mechanical Line Leak Detector. Model: FX/V ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: FLAPPER Z Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other(specify e ui ment e and model in Section E on Page 2). ❑ Other (specifX e ui ment e and model in Section E on Pa e 2). Tank ID: 87 Tank ID: DIESEL 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: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: FLAPPER Z Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specifX equipment e and model in Section E on Pae 2). ❑ Other (specifl e ui ment type and model in Section E on Pae 2). Dispenser ID: 11=2 Dispenser ID: 55®6 Z Dispenser Containment Sensor(s). Model: BEAUDREAU Z Dispenser Containment Sensor(s). Model: BEAUDREAU Z Shear Valve(s). Z Shear Valve(s). Z Dis enser Containment Floats and Chain(s). Z Dispenser Containment Floats and Chain(s). Dispenser ID: 3_4 Dispenser ID: 7s8 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: 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). ❑ Dispenser Containment Floats 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 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): Z System set-up Z Alarm history report Technician Name (print): MIKE LAWRENCE Signature: Certification No: A26642 I License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707) 446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 7T Date of Testing/Servicing: AUG 5, 2009 Page I of 3 Monitoring System Certification