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MONIAUNG SYSTEM CERTIFOATION 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 Mfflftpjng 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 Make/Model of Monitoring System:Veeder-Root Date of Testing/Servicing: 11-21-07 B. Inventory of Equipment Tested/Certified Check the appE2p!lLte boxes to indicate specift Equipment ins cted/serviced: Tank in): I F3 1! i, Tank ID: In-Tank Gauging Probe. Model:M-7 3TO og U In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 0. 2.0 L3 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: -)54-3-010- 2,0�0 C3 Piping Sump/Trench Sensor(s). Model: L3 Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: 6-TV-kq_,_D U Mechanical Line Leak Detector. Model: LI Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Model: [3 Tank Overfill/High-Level Sensor. Model: U Tank Overfill/High-Level Sensor. Model: U Other(specify Squ ,!pment e and model in Section E2a P 2). U Other�geciLy equipMent e and model in Section E on Page 2). Tank ID: Tank ID: U In-Tank Gauging Probe. Model: Ll In-Tank Gauging Probe. Model: [3 Annular Space or Vault Sensor. Model: U Annular Space or Vault Sensor. Model: • Piping Sump/Trench Sensor(s). Model: U Piping Sump/Trench Sensor(s). Model: • Fill Sump Sensor(s). Model: U Fill Sump Sensor(s). Model: LI Mechanical Line Leak Detector. Model: U Mechanical Line Leak Detector. Model: • Electronic Line Leak Detector. Model: LI Electronic Line Leak Detector. Model: • Tank Overfill/High-Level Sensor. Model: Ll Tank Overfill/High-Level Sensor. Model: 13 Other t!MifX S!ajgment pTe and model in Section E on P e 2). U Other(!geciLy equipment e and model in Section E on Page 2). Dispenser 111): L)1VAAACC )SL I Dispenser ID: 3d Dispenser Containment Sensor(s). Model:'-) !k�Q- Z L3 Dispenser Containment Sensor(s). Model: W Shear Valve(s). Ll Shear Valve(s). L3 Di ser Containment Flos)and Chain(sJ._ U Dispenser Containment Floats and Chain s). Dispenser ED: Dispenser El): U Dispenser Containment Sensor(s). Model: Ll Dispenser Containment Sensor(s). Model: Ll Shear Valve(s). [3 Shear Valve(s). 13 DiMEnser Containment Floats and Chain s). 0 Di ser Containment Floats and Chain s). Dispenser ED: Dispenser ID: Ll Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: El Shear Valve(s). U Shear Valve(s). UDiTenser Containment Floats and Chains U Digenser Containment Flo a 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/erviced 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 eq ipmen apable of gene ting such reports,I have also attached a copy of the report;(check all that apply): X System set-up 0 Ala Mry repo n 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.: 951-681-0708 Site Address: 1990 Piccoli Street,Stockton Ca.95215 Date of Testing/Servicing: 11-21-07 Page I of 3