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k:,4/10/2015 7: 10A4 FAX 19259 371 Guadalupe Sanchez f�0001/0015 MONITORING SYSTEM CERTIFICATION 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 e i1f!r[' f or re ort must be prepared for each monitoring m control partel by the tc n e rk. A cT3§j to the tank system owner/operator. The owner'/operator must submit a Copy to 41 n ul9;q W,jr%jNV"cd 30 days of test date. A. General Information APR 10 2015 S��Z j dad Facility Name: ARP Mini Mart 76 A Bldg.No.. Site,Address: 25775 So. Patterso Iritah—PhoT!N Zip: 95376 Facility Contact Person: Neil Patel ,T�4 co pT��C�to.: (510) 299-1219 MakefModel of Monitoring System: Veede`r Root TLS-350 Datta ofTesting/Servicing: 3/1012015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indieste specific c ui ment inspected/serviced: Tank TD: T1: 87 Slave Tank ID: T2: 87 Master Z In-Tank Gauging Probe, Model: 847390-107 M In-Tank Gauging Probe. Model: 847390-107 Annular Space or ,Vault Sensor, Model: 794390-407 Z Annular Space or Vault Sensor, Model; 794390-407 N Piping Sump/Trench Sensor(s). Model- 794380-208 M Piping Sump/Trench Sensor(s). Model: 794380.208 ®Pitl Sump Scnsor(s), Model: 794380-208 ®Fill Sump Scnsor(s), Model: 794380-208 ❑Mechanical Line Leak Detector, Model: ❑Mechanical Line Leak Detector, Model; ❑Electronic Line Leak Detector. Model: M Electronic Line Leak Detector. Model: 8484 ❑Tank Overfill/High-Lcvcl Sensor. Model: ❑Tank Ovcrfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2), ❑Other(specify equipment typo and model in Section E on Page 2). Tank 1D: T3: 87 Siphon Tank w: T4: 91 N Li-Tank Gauging Probe. Model: 847390-107 M hi-Tank Gauging Probe, Model: 848390-107 N Annular Space or Vault Sensor. Model: 794390407 Z Annular Space or Vault Scnsor, Model; 794390-407 M Piping Sump/-french Scnsor(s), Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Fill Sump Sensor("). Model: 794380-208 M Fill Sump Sensor(s). Model: 794380-208 �]Mechanical Line Leak Detector. Model; 0 Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: M 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). ❑Othcr(specify equipment type and model in Section F on Page 2), Dispenser ID: 1&2 Dispenser ID: 3&4 N Dispenser Containment Sensor(s). Model: 794380-208 M Dispenser Containment Scnsor(s). Model: 794380-208 N Shear Valvc(s). Z Shear Valve(s). ❑Dispenser Containment Flont(s)and Chain("), ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 Z Dicpen"er Containment Sensor(s), Model: 794380-208 M Dispenser Containment Sensor(s). Model: 794380-208 M Shear Vulve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispcnser Containment Fluat(s)and Chain("), Dlspensor ID' Dispenser ID: ❑1.)ispcnscr Containmcnt Scnsor(s). Model: 0 Dispenser Corttainment Semor(s), Model; ❑Shear Valve("). Q Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Flost(s)and Chain(s), ,1I17the facility contains more tanks or dispensers,'copy this form. Include information for every tank and dispenser at the facility, C. Certification -1 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 layoutof monitoring a uipment. For any eq un ment 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 - --Z/ — 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 ouresting/Servicing: 3/10/2015 Page 1 of 4 Rev(2/08)