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MONITQWNG SYSTEM CERTIFI TION FlWe By All Jurisdictions Within the State of Califon Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 76, Division 3 Title 23, Ca ifomia 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== 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: H & M (BOYETT PETROLEUM) Site Address: 2501 E JACKSON AVE Facility Contact Person: MANAGER Make/Model of Monitoring System:VRTLS350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced City: ESCALON Contact Phone No: 838-3971 Date of Testing/Service: 07/21/2005 Work Order Number: 2237589 CA Zip: 95320 TanklD: 1 TanklD: 2 X In -Tank Gauging Probe. Model: MAG X In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 420 X Annular Space or Vault Sensor. Model: 420 X Piping Sump/Trench Sensor(s). Model: 208QX Piping Sumplrrench 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 Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: MECHANICAL X Tank Overfill/High-Level Sensor. Model: MECHANICAL Other (specify equipment type and model in Section E on page 2). Other (specify equipment type and model in Section E on page 2). TankiD: U TanklD: X In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 208 Piping SumplTrench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FX1 DV Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X1 Tank Overfill/High-level Sensor. Model: MECHANICAL 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 QDispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: ® 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: Dispenser ID: FlDispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). 7 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser lD: ® Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). 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-upX❑ Alarm history report Technician Name (print): RAYMOND SIMMS Certification No.: 006-05-082 Signature: License. No.: Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 07/21/2005 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01