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MON&RING SYSTEM CERTI4ATION 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 must be used to document testing and servicing of monitoring equipment A separate certification or report must be prepared for each monitorine System control panel 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 FacilityName: ARCH ROAD ARCO AM PM Bldg.No.: Site Address: 4855 S. Highway 99 Frontage Road City: Stockton CA Zip: 95215 Facility Contact Person: Gill Contact Phone No.: (209) 948-2438 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 12/31/2009 B. Inventory of Equipment Tested/Certified Check thea propriate boxes to indicatespecific equipment inspected/serviced: Tank ID: Tank ID: ❑In-Tank Gauging Probe, Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Madel: ❑Piping Sump/Trench Sensor(s). Model: ❑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/High-Level Sensor. Mo ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and m in Section E on Page 2). ❑Other(specify equipment type and mod Section E on Page 2). LO ID: Tank ID: ank Gauging Probe. Model: ❑Tn-Tank Gauging Probe. Model: ular Space or Van ensor. Model: ❑Annular Space or Vault nsor. Model: ng Sump/Tr t t Senscr(s). Model: ❑Piping Sump/Tre Sensor(s). Model: Sump Se r(s). Model: ❑Fill Sump Se r(s). Model: ham Line Leak Detector. Model: ❑Mechmi Line Leak Detector. Model: nic Line Leak Detector. ModeC ❑Etc nic Line Leak Detector. Model: k Overfill/High-Level Sensor. Model: k Overfill/High-Level Sensor. Model: er(specify equipment type and model in Section Eon Page 2). Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 13/14 Dispenser ID: 15/16 ®Dispenser Containment Sensor(s). Model: 323 Z Dispenser Containment Sensor(s). Model: 323 ®Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: 17/18 Dispenser ID: Z Dispenser Containment Sensor(s). Model: 323 ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ED: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Cham(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 E Alarm history report Technician Name(print): Guadalupe Sanchez SignatVe,��M Certification No.: A30138 License.No.: 883706 611 Testing Company Name: Reliable Petroleum Service Inc. Phone No.:(20 8) 845-8586 Testing Company Address: 521 Branding Iron Street Oakdale CA 95361 Date of Testing/Servicing: 12131/2009 Page 1 of 4 UN-036—1/4 www.unidoes.org Rev.01/17/08