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MONITANG SYSTEM CERTIFIC ION J 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 toga local agency regulating UST systems within 30 days of test date. S A. General Information C,� j �® Facility Name: Unified Western Grocers Site Address: 1990 Piccoli Street Facility Contact Person: Pat GuillermM Bldg. No.: City: Stockton DEC 1 G ?a1� zip: 95215 pmM EWdHt bme No.: (323) 264-5200 Make/Model of Monitoring System: Veeder-Root TLS 350 R� Daae ooCting/Servicing: 11/28/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates cific a ui ment ins ted/serviced: Tank ID: T 1 — Diesel Tank ID: T 2 — Diesel I@ 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: OO 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 2qu!pEent a and model in Section E on Page 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: ❑ Others ui ment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser 01 Dispenser ID: ISI Dispenser Containment Sensor(s). Model: 794380420 ❑ Dispenser Containment Sensor(s). Model: ® 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 Float(s) and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Di enser Containment Fl s and Chain(s). ❑ Dis ser 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 ' spected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturer ' hecklists) necessa to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For an eq ipment capable o aerating such reports, I have also attached a copy of the report; (check all that apply): © System set-up arm histo repo Technician Name (print): Asa Cosby Signature: / " Certification No.: A-22350 License. No.: A-HAZ 9625 Testing Company Name: WSP Group Inc. Phone No.:(909) 597-9702 Site Address: 1990 Piccoli Street Stockton, Ca 95215 Date of Testing/Servicing: 11/282011 Page 1 of 3 03/01