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MONARING 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, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must berep pared 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: Unified Western Grocers Bldg.No.: Site Address: 1990 Piccoli Street City: Stockton,Ca Zip: 95215 Facility Contact Person: Pat Guillermety Contact Phone No.:(323)264-5200 ie-take/Model of Monitoring System: Veeder-Root Date of Testing/Servicing: 11-21-07 B. Inventory of Equipment Tested/Certified Check the aperooriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 1 Tank ID: In-Tank Gauging Probe. Model: "1 rLO- jC�`j ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 'VA'.f' - 7-0 O Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: -)43%0- 2-z"c-j 0 Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model:_ ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: $T�D-1,t L� ❑ 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: ❑ Others ci ui ment a and model in Section E on Page-2). ❑ Other(speci&a ui ment ty2e and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault 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: J Tank Overfill/High-Level Sensor. Model 0 Tank Overfill/High-Level Sensor. Model: 0 Other(s ecify equipment a andmodel in Section E on Pae 2). ❑ Other(s ecif a ui ment t e and model in Section Dispenser ID: f Dispenser ID: �J Dispenser Containment Sensor(s). Model: -;,q L). Q Z® ❑ Dispenser Containment Sensor(s). Model: ' Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). 0 Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID:. ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). O Shear Valve(s). ❑ Dispenser Containment Floats and Chains. O Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dis enser 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' checklis ) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipmen apable of gene ting such reports,I have also attached a copy of the report;(check all that apply): X System set-up xO Alar i-tory repo Technician Name(print):Asa Cosby Signature: Certification No.:A22350 License.No.:A-653381 A-Haz Testing Company Name: A&J Environmental Services Inc. Phone No.:951-681-®7®8 Site Address: 1990 Piccoli Street,Stockton Ca.95215 Date of Testing/Servicing: 11-21-07 Page 1 of 3