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ONI NG SYSTEM CERTIF TION Use By All Jurisdictions Within the State of CaliforMW Authority Cited: Chapter 6.7, alth 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. If more than one monitoring system control panel is installed at the facility, 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: COUNTRY SIDE MINI MART Site Address: 14971 N HWY 88 Facility Contact Person: GARY BURGIN Make/Model of Monitoring System:V/R TLS 250 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced City: LODI Contact Phone No: 368-5380 Date of Testing/Service: 02/21/2006 Work Order Number: 2241111 CA Zip: 95240 Tank ID: RUL Tank ID: PUL 71 In -Tank Gauging Probe. Model: MAG -1 X In -Tank Gauging Probe. Model: MAG -1 X Annular Space or Vault Sensor. Model: 420 X1 Annular Space or Vault Sensor. Model: 420 X Piping Sump/Trench Sensor(s). Model: 208 X1Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: MLD Mechanical Line Leak Detector. Model: 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 (specify equipment type and model in Section E on page 2). Tank ID: U5L Tank ID: X In -Tank Gauging Probe. Model: MAG -1 In -Tank Gauging Probe. Model: X1 Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FX1 DV Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank OverfilltHigh-Level Sensor. Model: Other (specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). Dispenser : 1/2 Dispenser ID: 3.4 3q Dispenser Containment Sensor(s) Model: 208 X Dispenser Containment Sensor(s) Model: 208 Q Shear Valve(s). X Shear Valve(s) E] Dispenser containment Float(s) and Chain(s). 7 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser lD: FiDispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: FlShear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). 71 Dispenser Containment Float(s) and Chain(s). Dispenser lD: Dispenser lD: F]Dispenser Containment Sensor(s) Model: 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). * 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the (Check all that apply): System set-upAlarm history report Technician Name (print): HEATH MCEVER Certification No.: 1931 Signature: _ License. No.: Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 02/21/2006 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01