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t, 751/1 MONI*RING SYSTEM CERTIF�TION For Use By All Jurisdictions Within the State of&U rornia' Authority CitedChapter 6.7,Health and S*1y Code;Chapter 16,Division 3, Title 23, California Code o T This form must be used to document testing and servicing of monitoring equipment Ase ggrtifir Ac - ,@Ltion or Lep2rt nut r monitoring Usttem controIpgnel by the technician who performs the work. A copy of this form must be provided to the . stemir/.S 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 VIC6� N Facility Name: 186249 Amo 6347-Tmqy Bldg.No.: Site Address: 2430 Joe Pombo City: Tm9j Zip: 95376 Facility Contact Person: Raqjit Contact Phone No.: (209) 830-8778 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 10/912007 B. Inventory of Equipment Testi d/Certiried Check the aggroLdate boxes to indicate smiflc Sgigment ins m.Mg ted/serviced: Tank iD: T-1 87 Master Tank iD. T-2 87 Slave 0 In-Tank Gauging Probe. Model: 847390-107 In-Tank Gauging Probe. Model: .847390-107 0 Annular Space or Vault Sensor. Model: 794380402 ❑Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 794380-323 Piping Sump/Trench Sensor(s). Model: 794380-323 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model; 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 331196-001 El Electronic Line Leak Detector. Model: [I Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: [j Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Tank w: T-3 91 Tank ID: 0 In-Tank Gauging Probe. Model: 847390-107 [1 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 79-4380-302 0 Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 794380-323 [1 Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s), Model: ❑Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 331196-001 El Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 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 ED: 112 Dispenser ID: 314 0 Dispenser Containment Sensor(s). Model: 7943W323 0 Dispenser Containment Sensor(s). Model: 794380-323 El Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ED: 616 Dispenser ID: 718 0 Dispenser Containment Sensor(s). Model: 794380-323 0 Dispenser Containment Sensor(s). Model: 794380-323 El Shear Valve(s), 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ED: 9110 DispenserID: 11112 0 Dispenser Containment Sensor(s), Model: 794380-323 0 Dispenser Containment Sensor(s). Model: 794380-323 0 Shear Valve(s). n Shear Valve(s). [I Dispenser Containment Float(s)and Chain(s). 0 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 inspect 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 equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up Alarm history report Technician Name(print): Gavin Williams Signature Certification No.: WIKT2074 License.No.: 05857 Testing Company Name: HMC-Henderson Maint Co Phone No.:(209) 467-7573 Site Address: PO Box 31325,Stoickton,CA 95213 Date of Testing/Servicing: 101912007 Page 1 of 3