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MONITORING SYSTEM CERTIFICATION Fr a By All Jurisdictions Within the State of California Authority Cited.*Chapter 6.7, He>✓and Safety Code;Chapter 16,Division 3 Title 23, Carfnia 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 mnedopemtor 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: TRACY PETRO City: TRACY CA Zip:95376 Site Address: 3400 N.MACARTHUR DR Contact Phone No: 814-8581 Date of Testing/Service: 02/25/2011 Facility Contact Person: KARAM SINGH Make/Model of Monitoring System:VR-TLS350 PLUS Work Order Number: 2279670 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: T1-PRE Tank ID: T2-REG X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 302 Annular Space or Vault Sensor. Model: 302 )( Piping Sumprrrench Sensor(s). Model. 208208 Piping Sumplfrench Sensor(s). Model: X Fill Sump Sensor(s). Model 208 208 X Mechanical Line Leak Detector. Model: LD2000 NX Mechanical Line Fill LLea Fill Sump Sensk Detector. Model Model: LD2000 ea Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: -XI Tank Overfill/High-Level Sensor. Model: EXT.ALARM Tank Overell/High-Level Sensor. Model: EXT.ALAR. Other(specify equipment type and model in Section E on page 2). Others eci ( p y equipment type and model in Section E on page 2). TanklD: Tank ID: 71 In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 302 Annular Space or Vault Sensor. Model X Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector, Model: LD2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: EXT.ALARM Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Other(specify equipment (s pe ty type and model in Section E on page 2). Dispenser : 1/2 Dispenser ID: 3/4 ®Dispenser Containment Sensor(s) Model:208 X Dispenser Containment Sensor(s) Model:208 X❑Shear Valve(s). X Shear Valve(s) ❑Dispenser Containment Floats)and Chalets). 7 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 X❑Dispenser Containment Sensgr(s) Model:208 X Dispenser Containment Sensor(s). Model'208 X❑ 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). ❑ 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, 1 have also attached a copy of the(Check all that apply): ❑System Set-up X❑Alarm history report Technician Name(print): KELVIN CRUZ Signature: Certification No.: A22519 License.NO.: 743160(Class'A'General Engmedng Contractor License) Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 11000 N.MoPac Expressway,suite 500,Austin,TX 78759 Date of Testing/Servicing: 02/25/2011 Monitoring System Certitication Page 1 of 3 Based on CA form dated 03/08