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MON*IUNG SYSTEM CERTIF �;ATION 1 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�0 V s. This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must 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. H FR 2 7 ZO 15 A. General Information ' ENVIRONMENTAL HEALTH Facility Name: ARP Mini Mart 76 BY#W/SERVICES Site Address: 25775 So. Patterson Rd. City: Tracy, Ca. Zip: 95376 Facility Contact Person: Neil Patel Contact Phone No.: (510) 299-1219 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 3/10/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: T1: 87 Slave Tank ID: T2: 87 Master 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: 794390407 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), Tank ID: T3: 87 Siphon Tank ID: T4: 91 Z In-Tank Gauging Probe. Model: 847390-107 Z In-Tank Gauging Probe. Model: 846390-107 Z Annular Space or Vault Sensor. Model: 794390-407 Z Annular Space or Vault Sensor. Model: 794390407 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: ElElectronic Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: 8484 [:]Tank Overfill/High-Level Sensor. Model: ElTank Overfill/High-Level Sensor. Model: ElOther(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: 1802 Dispenser ID: U4 Z Dispenser Containment Sensor(s). Model: 794380-208 Z 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: 5806 Dispenser ID: 7808 Z Dispenser Containment Sensor(s). Model: 794380-208 Z 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: 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,I have also attached a copy of the report;(check all that apply): ®System set-up ®Alarm history report Technician Name(print): Guadalupe Sanchez Signature: C. 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: 3/10/2015 Page 1 of 4 Rev(2/08)