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MONITOJNG SYSTEM CERTIFIC,. TION 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 monitoring system control panel by the technician who performs the work. A copy of thi Epe tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST s ti ate. A. General Information Facility Name: ARP MINI MART APR 2 12009 Bldg.No.: Site Address: 25775 S. Patterson Pass Road city: UNMENT HEALTH Zip: 95376 Facility Contact Person: Nailsh Patel Co 835-7777 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 3/27/2009 B. Inventory of Equipment Tested/Certified Check the approuriate boxes to indicate s cific equipment inspected/serviced: FTank 1D: T1: 87 Blue Slave Tank 1D: T2: 87 Blue Master n-Tank Gauging Probe. Model: 847390-107 ®In-Tank Gauging Probe. Model: 847390-107 nnular Space or Vault Sensor. Model: 794390-407 Z Annular Space or Vault Sensor. Model: 794390-407 iping Sump/Trench Sensor(s). Model: 794380-208 Z 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: Z 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: 87 Blue Syphon Tank ID: T4: 91 Gold Z In-Tank Gauging Probe. Model: 847390-107 Z In-Tank Gauging Probe. Model: 847390-107 Z Annular Space or Vault Sensor. Model: 794390-407 Z Annular Space or Vault Sensor. Model: 794390-407 Z Piping Sump/Trench Sensor(s). Model: 794380-208 Z Piping Sump/Trench Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z 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). Dispenser ID: 1 &2 Dispenser ID: 3&4 ®Dispenser Containment Sensor(s). Model: 794380.208 ®Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z 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 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser 1D: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑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,l have also attached a copy of the report;(check all that apply): Z System set-up Z Alarm history report Technician Name(print): Guadalupe Sanchez Signature: ems 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: 2/27/2009 Page 1 of 4 Rev(2/08)