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MONI01UNG SYSTEM CERTIARATION RECEIVED 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 Code tq,j,&R¢ulgtigns'13 This form must be used to document testing and servicing of monitoring equipment. 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 tott dlhuf/ QerLTH The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test a[ePERMIT/SERVICES A. General Information Facility Name: ARCO Bldg.No.: Site Address: 4855 S. State Route 9 City: Stockton, Ca. Zip: 95215 Facility Contact Person: Gill Contact Phone No.: (209) 481-7445 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 11/1912013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 TanklD: 89 Z In-Tank Gauging Probe. Model: 847390-109 Z In-Tank Gauging Probe. Model: 847390-109 Z Annular Space or Vault Sensor. Model: 794390-407 Z Annular Space or Vault Sensor. Model: 794390-407 Z Piping Sump/Trench Sensor(s). Model: 794380-323 Z Piping Sump/Trench Seasons). Model: 794380-323 Z Fill Sump Sensor(s). Model: 794380-344 Z Fill Sump Seasons). Model: 794380-323 ❑Mechanical Line Leak Detector. Model: Z Mechanical Line Leak Detector. Model: 99LD-2000 Z Electronic Line Leak Detector. Model: RJ 244-006-5 ❑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). TanklD: 91 TanklD: Z In-Tank Gauging Probe. Model: 847390.109 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390.407 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-323 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Seasons). Model: Z Mechanical Line Leak Detector. Model: 99LD-2000 ❑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: E] 8h ❑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: 1&2 Dispenser ID: 38,4 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: 58,6 Dispenser ID: 78,8 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Cham(s). Dispenser ID: 98,10; 11&12 Dispenser ID: 13&14; 158,16; 17&18 Z Dispenser Containment Seasons). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floats)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 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 istory report Technician Name(print): Guadalupe Sanchez Signatu -- cal Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd, Oakdale,Ca. 95361 Date of Testing/Servicing: 11119/2013 Page 1 of 4 Rev(2/08)