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MONITRRING SYSTEM CERTIFI�TION For By All Jurisdictions Within the State of Cali a 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 rQp4DW dach monitoring_system control panel by the technician who performs the work. A copy of this form must be provided to th r 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 DEC 30 2010 Facility Name: ARCO Site Address: 4855 S. State Route 99 City: Stockton,Ca. PAI Facility Contact Person: Gill Contact Phone No.: (209) 481-7445 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 11/2412010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates kilo a ui mcnt ins ected/serviced: Tank ID: 87 Tank ID: 89 ®In-Tank Gauging Probe. Model: 847390-109 ®In-Tank Gauging Probe. Model: 847390-109 ®Annular Space or Vault Sensor. Model: 794390-407 ®Annular Space or Vault Sensor. Model: 794390-407 ®Piping Sump/Trench Sensor(s). Model: 794380-323 ®Piping Sump/Trench Sensor(s). Model: 794380323 ®Fill Sump Sensor(s). Model: 794380344 ®Fill Sump Sensor(s). Model: 794380323 ❑Mechanical Line Leak Detector Model: ®Mechanical Line teak Detector. Model: 99LD-2000 ®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), Tank ID: 91 Tank ID: N In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: 794390.409 ❑Annular Space in Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 794380323 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensm(s). Model: 794380323 ❑Fill Sump Sensor(s). Model: E 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: ❑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: 182 Dispenser ID: 3&4 ®Dispenser Containment Sensor(s). Model: 794380-323 ®Dispenser Containment Sensor(s). Model: 794380323 ®Shear Valve(s). ®Shear Valve(s). ❑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: 794380-323 N Dispenser Containment Semor(s). Model: 794380-323 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Morals)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9&10 Dispenser ID: 11&12 ®Dispenser Containment Seasons). Model: 794380-323 ®Dispenser Containment Sensur(s). Model: 794380323 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser containment Float(s)and Chain(s). ❑Dispenser containment Floats)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 equr mens For any equi ment capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up L9 Alarm history report Technician Name(print): Guadalupe Sanchez Signature: "" 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: 11/2412010 Page 1 of 4 Rev(2/08)