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, MONITANG SYSTEM CERTIFIC$r10N 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 of Regulations This form most be used to document testing and servicing of monitoring equipment. A se arate certification or ie must re red fore o monitoring system control panel by the technician who performs the work. A copy of this form must be provided to st The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test A. General Information JAN 0 5 2012 Bldg.No Facility Name: ARCO City: Stockton, Ca. ENM Site Address: 4855 S.State Route 9 Contact Phone No.: (209) 481-7445 Facility Contact Person: Gill Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 1113012011 B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to indicates ecific a ui ment ins ected/serviced: Tank ID: 87 Tank ID: 89 In-Tank Gauging Probe. Model: 847390-107 ®In.T>,nk.Craug;nggrobe. Model: 847390-107 ®AnnWar,S ace or Vault Sensor. Model: 794390-0(17 ®Annular Space or Vault Sensor. Model: 79439007 Piping Sum hTrench Sensor(s). Model 794380.323 ®Piping Sump/Trench Sensor(s). Model: 794380-323 ® P g. P Model 794390-323 ®Fill Sump Sensor(s). Model: 794380-344 ®Fill Sump Sensor(s). ®Mechanical Line Leak Detector. Model: 99LD-2000 E)Mechanical Line Leak Detector. Model: Electronic Line Leak Detector- Model: ®Electronic Line Leak Detector. Model: RJ 244-006-5 Q Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: age 2). ❑other(specify equipment type and model in Section Eon Page 2). Cl other(specify equipment type and model in Section E on P Tank ID: Tank ID: 91 probe AnnulModel ®Annul E]Gauging Probe. Model: 847390-107 In-Tank Gauging ® Annular [1A Annular Space or Vault Sensor. Model Space or Vault Sensor. Model: 794390.409 ®Piping Sump/Trench Seawr(s). Model: 794380323 ❑Piping Sump/Trench Sensor(s).: . Model ®Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(s). Model - Mechanical Line Leak Detector: Model: ®Mechanical Line Leak Detector. Model: 99LD-2000 ❑Electronic Line Leak Detector Model ❑Electronic Line Leak Detector. Madel _ - ❑Tank Overfill/Higb-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: El (specify equipment type and model in Section E.on Page 2): [I Other(specify equipment type and model in Section E on Page 2). Dispenser ID:.1&2 Dispenser ID: 3&4 ®Dispenser Containment Sensor(s). Model: 794380323 - ®Dispenser.Containment Sensor(s). Model: 794380323 - Shear Valve(s). ®Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s).. - Dispenser ID: 5&6 Dispenser ID: 7&8 — ®Dispenser Containment Sensor(s). Model: 794380323 ®Dispenser Containment Sensor(s). Model: 794380-323 ®Shear V alve(s). ®Shear Valve(s). ❑Dispenser Containpient Float(s)and Cham(s). rODispenser Containment Floaz(s)and Chairi(s).ser ID: 9&10; 11&12 Dispenser ID: 13&14; 15&16® Dispenser Containment Sensor(s). Model: 794380enser Containment Sensor(s). Model: 794380323 ®Shear Vnive(s): ar Valve(s). _enser Containment Floats)and Chaio(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.Ce the layout s information formating(e.g.ma u �F f sn checklists) dnecessary to verify able of generatingsuch this information is correct and a Plot Plan showing Y y equipmentp reports,I have also attached a copy of the report;(check all that apply): ®System set-up ®Alarm history r rt Technician Name(print): Guadalupe Sandw Signgttlre: 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: 11/3012011 Page 1 of 4 Rev(2/08)