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MONIPORING 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 Facility Name: Unified Western Grocers Site Address: 1990 Piccoli Street city: Stockton Facility Contact Person: Pat GuillernletV Make/Model of Monitoring System: Veeder-Root TLS 350 B. Inventory of Equipment Tested/Ce ° ied ( Check the appropriate boxes to indicate specific equipment inspected/serviced: I I . 0 1 0 1 , 6 0 11 Date of Testing/Servicing: 12/3/2009 Tank ID: T 1— Diesel Tank ID: T 2 — Diesel M In -Tank Gauging Probe. Model: 847390-107 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 794390420 ❑ Annular Space or Vault Sensor. Model: ® 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. 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 P e 2). ❑ Other (specify equipment type and model in Section E on Page 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. 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 a ui ment a and model in Section E on P e 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser 01 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 794380-420 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). Ll Shear Valve(s). L3Dis enser 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 Float(s) and Chain(s). ❑ Dispenser Containment Float s) and Chain(s). Dispenser ID: Dispenser : ❑ 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 Chain(s). *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Ce °kation - 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' ch klists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equi ent capable of generating such reports, I have also attached a copy of the report; (check all that apply): ® System set-up I hist report 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 License. No.: A - Phone No.:(9091 Date of Testing/Servicing: 12/32009 Page 1 of 3 03/01