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11 Monitoring System Certification 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, Califomia 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 Facilty Name: Verizon KINGCA Site Address: 13850 Devries Facility Contact Person: Colby Hoepfner Make/Model of Monitoring System: Pneumercator TMS2000 B. Inventory of Equipment Tested/Certified Check the a propriate boxes to indicate specific equipment inspectediserviced: Bldg. No.: City: Lodi Zip: Phone: (972) 729-5182 Date if Testing/Service: 09/13/07 P Tank ID: Diesel Tank ID: ❑✓ In Tank Guaging Probe. Model: 450 ❑ In Tank Guaging Probe. Model: ❑✓ Annular Space Sensor. Model: LS610 ❑ Annular Space Sensor. Model: ❑✓ Piping Sump / Trench Sensor(s). Model: LS600 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High Level Sensor. Model: ❑ Tank Overfill / High Level Sensor. Model: Other (specify equipment a and model in Section E on Page 2). F1 other (sDecifv equipment a and model in Section E on Page 2 . TankID: ank ID: ❑ In Tank Guaging Probe. Model: ❑ In Tank Guaging Probe. Model: ❑ Annular Space Sensor. Model: ❑ Annular Space Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High Level Sensor. Model: ❑ Tank Overfill / High Level Sensor. Model: Other (specify equipment a and model in Section E on Page 2). Other (specify equipment a and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor. Model: ❑ Dispenser Containment Sensor. Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor. Model: ❑ Dispenser Containment Sensor. Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Dis enser Containment Floats and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor. Model: ❑ Dispenser Containment Sensor. 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 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): 2 System set-up ❑✓ Alarm History Report Technician Name: Robert Henninger Signature: Certification No.: 10588 Liscense No.: 396575 A / B/ C-10 / HAZ Testing Company Name: Balch Petroleum Phone No.: 408-942-8686 Site Address: 930 Ames Ave, Milpitas, CA Date of Testing/Service: 09/13/07 Page 1 of 3