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MONITORING SYSTEM CERTIFICATION For Use R1' All Jurisdictions Within the State of California Authority Cited. Chapter t5.7, Health and Safety Code, Chapter 16, 1)Ivfsion 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A §Q@Egg certificsttionter report must bg prepared foow monitoring system controi 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 66447 Bldg. No.: Site Address: 1469 E HAMMER LANE City: STOCKTON Zip: 95209 Facility Contact Person: ALLEN FAASS Contact Phone No.: (925) 8 Make/Model of Monitoring System: VEEDER--ROOT TLS -350 Date of Testing/Servicing: 712112014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specift equipment ins edWserviced: Tank]D: 91 Tank 1D: 89 ® in -Tank Gauging Probe. model: MAG in -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: 409 ® Piping Stamp / Trench Sensor(s). Model.. 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD2000 ® Mechanical Line Leak Detector. Model: LD2000 ❑ Electronic Lice Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: 87 Tank ID: DIESEL ® In -Tank Gauging Probe. Model: MAG ® Ira -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 409 ® Annular Spm or Vault Sensor, Model: 409 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD2000 ® Mechanical Line Leak Detector. Model: LD2000 D Electronic Line Leak Detector. Model: i❑ Electronic Line teak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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 ID: 112 Dispenser ID: 314 ® Dispenser Containment Sensor(s). Model: BEI 406 ® Dispenser Containment Sensor(s). Model: BEI 406 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ® Dispenser Containment Sensor(s). Model: BEI 406 ® Dispenser Containment Sensor(s). Model: BEI 406 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). [] Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9110 Dispenser ID: ® Dispenser Containment Sensor(s). Model: BEI 406 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment FW(s) 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 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 report Technician Name (print): RICHARD THOMAS Signature: t.. --a I--5 Certification No.: 834022 License. No.: 803705 Testing Company Name: TANK TEK ENVIRONMENTAL CORPORATION Phone No.: L707) 446.6151 Testing Company Address: 607 ELMIRA ROAD, PWB 336, VACAWUE, CA 95667 Date of Testing/Servicing: 712112014 Page I of 4 UN -036 — www.onWoes org Rev. 01/1798