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MONARING SYSTEM CERTIFOATION 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 fort must be used to document testing and servicing of monitoring equipment A seo to cc ific ti t d for each monitoring system control.panel by the technician who performs the work. A copy of this form must be p er/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 a , , A. General Information JAN 2 7 2010 Facility Name: ARCH ROAD ARCO AM PM &E} { AUH Site Address: 4855 S. Highway 99 Frontage Road City: Stockton CA GFRIIAIT/moi R 15 Facility Contact Person: Gill Contact Phone No.: (209) 948-2438 Make/Model of Monitoring System: Veeder Root TLS-360 Date of Testing/Servicing: 12131/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: T-1 Unleaded Tank ID: T-2 Mid Grade ®In-Tank Gauging Probe. Model: 109 ®In-Tank Gauging Probe. Model: 109 ®Annular Space or Vault Sensor. Model: 407 ®Annular Space or Vault Sensor, Model: 407 ®Piping Sump/Trench Sensor(s). Model: 323 ®Piping Sump/Trench Sensor(s). Model: 323 ®Fill Sump Sensor(s). Model: 344 ®Fill Sump Sensor(s). Model: 323 ❑Mechanical Line Leak Detector. Model: ®Mechanical Line Leak Detector. Model: 99 LD2000 ®Electronic Line Leak Detector. Model: RJ CPT ❑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 Age 2). Tank ID: T-3 Premium Tank ID: ®In-Tank Gauging Probe. Model: 109 ❑In-Tank Gauging Probe. Madel: ®Annular Space or Vault Sensor. Model: 407 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 323 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: 323 ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: 99 LD2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: [I Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Leve]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: 112 Dispenser ID: 314 ®Dispenser Containment Sensor(s). Model: 323 ®Dispenser Containment Sensor(s). Model: 323 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ®Dispenser Containment Sensor(s). Model: 323 ®Dispenser Containment Sensor(s). Model: 323 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ED: 9/10 Dispenser ID: 11/12 ®Dispenser Containment Senor(s). Model: 323 ®Dispenser Containment Sensor(s). Model: 323 ®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 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 history report G'Ve t- gn � rj p 1115 ec j7J( Technician Name(print): _Guadalupe Sanchez Si store: �y/ � Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Service Inc. Phone No.:(209) 845-8586 Testing Company Address: 521 Branding Iron Street Oakdale CA 95361 Date of Testing/Servicing: 12131/2009 Page 1 of 4 1JN-436—1/4 www.unidocs.org Rev.01/17/08