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MONITIRING SYSTEM CERTIFATION 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 Infoation Facility Name: Unified Western Grocers Site Address: 1990 Piccoli Street City: Stockton Facility Contact Person: Pat Guillerp ety Make/Model of Monitoring System: Veeder-Root TLS 350 B. Inventory of Equipment Tested/Certified —I. --o. +1. _; #_ 1.. +.. Oo 1-1. in.."ted/eerviepd- Bldg. No.: zip: 9521-5 Contact Phone N®.:(323) 264-5200 Date of Testing/Servicing: 12/3/2009 Tank ID: T 1- Diesel Tank ID: T 2 — Diesel El In -Tank Gauging Probe. Model: 847390-107 ❑ In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 794390420 ❑ Annular Space or Vault Sensor. Model: El Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FE Petro ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. Model: Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pae 2 . Tank ID: T 3 — Waste Oil Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). Model: 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 type and model in Section E on Page 2). ❑ Others eci ui ment a and model in SectionE on P e 2). Dispenser ID: Dispenser 01 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: © Dispenser Containment Sensor(s). Model: 794380-420 ❑ Shear Valve(s). ® Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Fioa s and Chains . ❑ D"q— Containment Floats) and Chains . *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 guidelines. Attached to this Certification is information (e.g. manufacturer: correct and a Plot Plan showing the layout of monitoring equipment. For any attached a copy of the report; (check all that apply): ® System set-up Technician Name (print): Asa Cosby Signature: _ Certification No.: A-22350 Testing Company Name: A & J Environmental Svc's Inc. Site Address: 1990 Piccoli Street Stockton Ca 95215 erviced in accordance with the manufacturers' o) necessary to verify that this information is capable generating such reports, I have also License. No.: A - Phone No.:(909) 597-9702 Date of Testing/Servicing: 12/3/2009 Page 1 of 3 03/01