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cEc 1 a gniA ENVIRONMENTAL HEAL�ooi/outs 12/15/2014 :57PM FAX ",3252380971 Guadalupe Sanchez DEPARTMENT MONITORING SYSTEM CERTIFICATION For Use By All Arisdictions Within the State ofcawornta .our oriry Cftdd:Chanter 6.7,Health and S4fery Lode;Chapter 16,Division 3, Title 33,California Code afRegs 1400nr This form ust be used to document testing and Servicing of monitoring equipment. 4 wenrM ceninoalfun or report must be prepared for each �ltnrjnk y9moontrolyanal by the technician who performs the work. A copy of this tbrot must be provided to live lank system owner/operator- The ownen/c nrator must submit a copy df this fbrmto the local agency regulating UST systems within 30 days of test date. A. Gene at Information Facility Nae: ARCO Bldg No.: Site Addrc s: 4866 S. State Route 9 City: Stockton,Ca, Zip: 95215 Facility Cc itact Pelson: GUI Contact Phone No.: 209 481-7445 M9&M 1ofMonbnngSystem: VeederRoot TLS-350 Date of Tcstirloorvicing: 111261'2014 B. Inve tory of Equipment Testc&CertiGed . Uieck(be at Pra date horns to indicatespecific e neral ins EcolcMcrviced: Tank ID: 7 Tank ID: 89 0In-Tank aging Probe, Model• 947390.109 ®In-Tank Gauging Probe, Model: 647390-109 9Aawlar IwoWVaal!Sooner. Model. 794390407 21 Annular Space aVault Sensou Mndel: 794390-407 ®Piping Su p/Trench Scntags} Modet 794380-323 ®Piping Sump/Trench SamuKs). WdG: 794380323 ®Fill Sun Smcer(s). Modeh 794380-344 ®F111 Sump SensoK%). Mudd: 794384323 _ ❑Mabom Line Leak ridector Moec1 ®Mcd:a,sloa7 Lina Leak Detector. :NOdel: 99LO.MCID ®Rloccami Line Leak Detector. Medd: RJ 244-008-5 ❑Eko&roamc Line teak Detector, Wdd: ❑Tank(n, il!High-Level Sensor. Model! ❑Tank Ovarfll/FEgh-Ixvel Banton Model: D Other S ify egwpment type and modal in Section L•or Page 2), f ❑Omar(spocify'Wuipmem type aid model in SeeLon L•on Pat„•a 21. Tank 1D' 1 Tank M; ®1n=1'ac Awginp Probc. Medd: 947390-109 ❑In-Tank Craugloe Probe. Mede[: to Annular Space a Vault Sarna. Modal 794390107 ❑Annular Space at Vault Sensor. Madel: M Piping Situp l Trench Sen:nt(5), MOM: 794300.323 0 PPInggump t 7ronch5ertsor(s). Model: ®F81 Sump SensoKs)" Mndd; 794380323 ❑p':II Sump Sensm(s). Model: 2WehaoiodLim Leak Detecta. Model: SSLD-2000 ❑Mechanical lift Look Detente, tvivjot: ❑FlecuOnicilns,.tate Detector. Model: ❑EIcvmnio Lmc:.eek Detector. Model: ❑Tank Ov.rfill/High-]svcl Sensor. Model: ❑TankOverfill!High-level Sensor. Model: ❑other(specify equipment type and model in SeotionE on Page2). ❑Other(spw*equipment type and model in Section E on Pam 2). Dispenser ID: 1&2 Disponscrim 3&4 i$D'upmsa Cortahuncat Scnsa(sl. Model: 794380.323 ®Dispenser Containment Semw(s). Model: 784390-323 ®SLcw Valvc;s), lZ Sheat Valve(s). a Q Dispenser Containment Fba Oend Cludals). ❑Dispenser Containment Flod(s)and Chain(s). DispmerfD: 5&6 DispeoserlD! Y&8 ®Dispenser CantainmaeSensur(s). Modcl: 7UUIl.323 ®Dispenser Containment Sertsor(s). Model: 794380323 Z Stew Vahras). R.Shaw Valve(s). ❑Dispeoser Containment Flom(s)end Chrin(s) ❑Dispenser Cantainmtnl Fbat(s)anJ Chain(s). _- Dispenser ID: 9&10;11&12 Dispenser ID: 13&14;15&16:17&18 ®Ihspenser Ccnraianen:Scnsar(s). M.odch 794380.383 ®DlspenserCtarta+nmmt Sensos(s). ModcL794380.323 ®Show Valvc(s). N Shear VAhon). Q Dispenser Crnmivneir.FI041(s)and Cba:[I(4). ❑rl7spmacr(:anainmcot Plom(s)and C'ham(s). •If the faciLly comains more tants or dispensers,copy this fora'.. Include Information for every tank and dispenser at the facility. C. CertlfiCatlOn - I certify that the equipment Identified in this document was inapecoo"etviad in accordance with the manufaetur'ers'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 egua meet capable of generating such reports,I have also attached a,copy of the report;(CNet*all that app&): Z System set-ttir %N Alarm history repail Technician Name(print): Guadalupe Sanchez Signatiue:�'`—T' CordficationNo.t A30138 Liccnse.No.: 883706 Testing company Name: Reliable Petroleum Services,Inc. Phone No.;(209) 84541586 Testing Company Address: 11930 Horseshoe Rd,Oakdale,Ca.95361 Date of Testingl5ervicing: 11/2512014 Page 1 of 4 • Rev(?As)