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ONIT NG SYSTEM CERTIOCATION 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 Si ature: Facility Name: BOYETT PETROLEUM #98 - H & M MARKET Bld . No.: Site Address: 2501 E. JACKSON AVE City: ESCALON I Zip: 95320 Facility Contact Person: ROHDA HENRY Contact Phone No.: (209) 549-5612 Make/Model of Monitoring System: VEEDER ROOT TLS 350 1 Date of Testing/Servicing: JULY 31, 2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: REGULAR Si ature: Tank ID: SUPER License: 803705 ® In -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® 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: FXIV 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 Z Tank Overfill / High -Level Sensor. Model: FLOAT ❑ Other (specifZ a ui ment e and model in Section E on Pa e 2). ❑ Other (speciti equipment t e and model in Section E on Pae 2). Tank ID: DIESEL Tank ID: Z In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: Z Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: FXIV ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: FLOAT ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Pae 2). ❑ Others eci a j!ment t e and model in Section E on Pae 2). Dispenser ID: 11-22 Dispenser ID: 33=4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Floats and Chain(s). Z Dis enser Containment Floats and Chains . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains . ❑ 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 —7Technician Name (print): MIKE LAWRENCE Si ature: 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: JULY 31, 2007 Page 1 of 3 Monitoring System Certification