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MONI RING SYSTEM RRECEIVED ''� SEM CERTIF.. _.ATICYI� For Use By All Jurisdictions Within the State of California N 2 0 2011 Authority Cited.• Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Co,e of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or r each monitoring_ system control panel by the technician who performs the work. A copy of this form must be provided to th�perator. 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: A -One Gas N Food Site Address: 574 W. Grant Line Rd. Facility Contact Person: Ramesh Sood Bldg. No.: City: Tracy, Ca. Zip: 95376 Contact Phone No.: (209) 523-6324 Make/Model of Monitoring System: Veeder-Root TLS -350 Date of Testing/Servicing: 12/17/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment insvccted/serviced: Tank ID: T1: 87 Tank ID: T2: 91 ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 794390-409 Z Annular Space or Vault Sensor. Model: 794390-409 Z Piping Sump / Trench Sensor(s). Model: 794380-208 Z Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: VMI 99LD-2000 Z Mechanical Line Leak Detector. Model: VMI 2000 ❑ 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: 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 (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 182 Dispenser ID: U4 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 586 Dispenser ID: 788 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z 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 fotm. 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 equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): Z System set-up ® Alarm history report Technician Name (print): Guadalupe Sanchez Signature: Certification No.: A30138 License. No.. 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.: (209) 845-8586 Testing Company Address: 11930 Horsheshoe Rd. Oakdale, Ca. 95361 Date of Testing/Servicing: 12/17/2010 Page 1 of 4 Rev (2/08)