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MONITWNG SYSTEM CERTIFIATION For By All Jurisdictions Within the State of Cali 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 orenared for each monitoring 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 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: 11/2412010 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates cifie ai ment ios etWmrviced: 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 Sensm(s). Model: 794380323 ®Piping Sump/Trench Seasons). Model: 794380-323 ®Fill Sump Seasons). Model: 794380-344 ®Fill Sump Sensor(s). Model: 794380-323 ❑Mechanical Line Leak Detector. Model: ®Mechanical Line Leak Detector. Model: 99LD-2000 ®Electronic Line Leak Detector. Model: RJ 244-0085 ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/Hi -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: ID In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: ®Annular Space m Vault Sensor. Model 794390.409 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensods). Model: 794380-323 ❑Piping Sump/Trench Seasons). Model: ®Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Scnsm(s). Model: ®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: 13814 Dispenser ID: 15816 ®Dispenser Containment Sensor(s). Model: 794380-323 ®Dispenser Containment Sensors). Model: 794380323 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Contaminant Float(s)and Cham(s). Dispenser ID: 17818 Dispenser ID: ®Dispenser Containment Seasons). Model: 794380323 ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floaz(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Cbain(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 az 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 equi ment For any equi meut capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up Alarm histoy report Technician Name(print): Guadalupe Sanchez Signature: a.a Certification No.: AMU License.No.: 883706 209 No.: 845-8586 Testing Company Name: Reliable Petroleum Services, Inc. Phone ( Testing Company Address: 11930 Horseshoe Rd, Oakdale,Ca.95361 Date of Testing/Servicing: 11/2412010 Page 1 of 4 Rev(2/08)