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MON RING SYSTEM CERTIFIDATION 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 Bldg. No.: Site Address: 1990 Piccoli Street city: Stockton zip: 95215 Facility Contact Person: Pat GuillermeV Contact Phone No.: (323) 264-5200 I Make/Model of Monitoring System: Veeder-Root TLS 350 Date of Testing/Servicing: 11/21/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T 1 —Diesel Tank ID: © In -Tank Gauging Probe. Model: 847390-107 ❑ In -Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: © Annular Space or Vault Sensor. Model: 794390-409 ❑ Piping Sump /Trench Sensor(s). Model: ® Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ® Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ® Mechanical Line Leak Detector. Model: Red Jacket FX1 V ❑ 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). ❑ Other (s eci a ui ment tyE and model in Section E on Pae 2). Tank ID: 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 �specia a ui ment a and model in Section E on Pae 2): ❑ Other �speci& ui ment a and model in Section E on Page 2). Dispenser ID: Dispenser 01 Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 794380-420 ❑ Dispenser Containment Sensor(s). Model: E3 Shear Valve(s). © Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s). ® 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 Float(s and Chain(s). ❑ Di enser 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). ❑Dis enser Containment Float s) and Chain(s). ❑ Dis enser 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. 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 checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any uipment capabit of generating such reports, I have also attached a copy of the report; (check all that apply): 0 System set-uplartn hist sport Technician Name (print): Asa Cosby Signature: Certification No.: A-22350 License. No.: C61-915 Testing Company Name: Total Petroleum Services Phone No.:909-377-5997 Site Address: 1990 Piccoli Street Stockton CA 95215 Date of Testing/Servicing: 1121/2012 Page 1 of 3 03/01