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MON.- JRING SYSTEM CERTI4ATION REff CENT D ForUlifornia Authority Cited. Chapter 6.7, Health and Safety Code,t Chapterisdic ions jrhl tS,in t Division 3, The State of itle 23,1 Ca"fornia Code o 1 s f� 1�� 2008 This form must be used to document testing and servicing of monitoring equipment. A separate certification or re rt monitorin¢system control panel by the technician who performs the work. A copy of this form must be provided to the tan TH The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. I� 01 ` 9"moi LI i:V;01 U...I A. General Information Facility Name: ARP MINI MART Bldg. No.: Site Address: 25775 So. Patterson Road City: Tracy Ca. Zip: 95376 Facility Contact Person: Neilsh Patel Contact Phone No.: (209) 835-7777 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 3/17/2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates cific a ui ment ins cted/serviced: F : T1: Blue Slave Tank ID: T2: Blue Master k Gauging Probe. Model: 847390-107 ®In-Tank Gauging Probe. Model: 847390-107 ar Space or Vault Sensor. Model: 794390-407 ®Annular Space or Vault Sensor. Model: 794390-407 Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ill Sump Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: 8484 ❑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: T3-Blue Siphon Tank ID: T4 Gold ®In-Tank Gauging Probe. Model: 847390-107 ®In-Tank Gauging Probe. Model: 847390-107 ®Annular Space or Vault Sensor. Model: 794390-407 ®Annular Space or Vault Sensor. Model: 794390-407 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: 8484 ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: [th er(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). enser ID: 1 + 2 Dispenser ID: 3+4 ispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208hear Valve(s). Shear Valve(s). ispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s).enser ID: 5+gDispenser ID: 7+8 ispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208ear Valve(s). Shear Valve(s). ispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). El 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 - Technician Namerint : Guadalupe Sanchez �P ) p Signature,:.v-�- Certification No.: A30138 License.No.: 883706 Testing Company Name: RELIABLE PETROLEUM SERVICES INC. Phone No.:(209) 845-8586 Testing Company Address: 521 Branding Iron St. Oakdale Ca 95361 Date of Testing/Servicing: 3/17/2008 Page 1 of 3