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I� s ),r MONITORING SYSTEM CERTIFICATION S For Use By All Jurisdictions Within the State of California !' Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California%C,q�+,f` ? i This form must be used to document testing and servicing of monitoring equipment. A separate certification for each monitoring system control 12anel 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: A.G. S anon Aviation Bldg.No.: Site Address: _4800 S Airport Way City. Stockton Zip: 95206 Facility Contact Person: Thomas Contact Phone No.: (209) 982-1550 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 212112008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s ecine a ui anent inspected/serviced: Tank ID: T1: Jet Fuel West Tank ID: T2:Jet Fuel East 0 In-Tank Gauging Probe. Model: 8473-90-109 ®ln-Tank Gauging Probe. Model: 8473-90-110 •Annular Space or Vault Sensor. Model: 794390-420 ®Annular Space or Vault Sensor, Model: 794390-409 •Piping Sump/Trench Sensor(s). Model: 794380-208 0 Piping Sump/Trench Sensor(s). Model: 794380-208 ❑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 I 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: T3 :Jet Fuel East 2 Tank ID: ®In-Tank Gauging be. Model: 8473-90-107 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390-409 ❑Annular Space or Vault Sensor. Model: ®Piping Sump 1 Trench Sensor(s). Model: 794380-208 ❑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 1 High-Level Sensor. Model: ❑Tank Overfill I 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: 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 Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sertsor(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). 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). I ❑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 -1 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): System set-up ®Alarm history report C Technician Name(print): Guadalupe Sanchez _ Signature• �- Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Phone No.: (209) 845-8586 Site Address: 521 Branding Iron St. Oakdale Ca.95361 Date of Testing/Servicing: 2/21/2008 Page 1 of 3