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MONITORING SYSTEM CERTIFIC *-TION I 'se By All Jurisdictions Within the State of Cahfcmh ` Authority Cited:Chapter 6.7,H�Pg' h and Safety Code;Chapter 16,Division 3 Title 23, omia 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 recon must be prewred for each monitoring system control oanel by the technician who performs the work. A copy of this forth must be provided to the tank system owner/operator. The owner/operator must submit a copy of this forth 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 Dale of Testing/Service: 02/26/2010 Facility Contact Person: KARAM SINGH Make/Model of Monitoring System:TLS350 Work Order Number: 2272570 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced TanklD: 91 TanklD: 87 _R1 In-Tank Gauging Probe. ModelMAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 302 Annular Space or Vault Sensor. Model: 302 X Piping Sump/Trench Sensor(s). Model. 206 Piping Sump/Trench Sensor(s). Model: 206 X Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 X Mechanical Line Leak Detector. Model: LD2000 X Mechanical Line Leak Detector. Model: LD2000 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: AUDIBLE Tank OveKlUHigh-Level Sensor. Madel: AUDIBLE 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 10: DSL Tank ID: In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: X1 Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Madel: X Mechanical Line Leak Detector. Model: LD2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 71 Tank Overfill/High-Level Sensor. Model: AUDIBLE Tank Overfiwigh-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 ®Dispenser Containment Sensor(s) Model:208 _Xj Dispenser Containment Sensor(s) Model:208 XJ Shear Valve(s). _X-1 Shear Valves) ❑Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 X❑Dispenser Containment Sensors) Model:208 X Dispenser Containment Sensor(s). M del:208 X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Flmt(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: F1Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chaeta). 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-up X❑Alarm history report Technician Name(print): DANIEL ROLLINS Signature: Certification No.: 835253 License.No.: 743160(Class'A'General Enginenng Contractor License) Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 11000 N. MoPac Expressway,suite 500,Austin,TX 78759 Date of Tesfing/Servicing: 02/26/2010 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08