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MONITORING SYSTEME �� ED C RTIFICATION For Use By All Jurisdictions Within the State of California W2017 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Codegtl ionstt This form must be used to document testing and servicing of monitoring equipment. _A_separate certification or report ` Ni4 9F-0M monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tan¢ iuiaERA�44or. 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: ARP Mini Mart Site Address: 25775 Patterson Pass Road Facility Contact Person: Nick Patel Make/Model of Monitoring System: Veeder-Root TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate .Specific equipment inspected/sere iced: City: Tracy Contact Phone No. _ Bldg. No.: Zip: (510) 600-3360 95377 Date of Testing/Servicing: 03/31/2017 Tank ID: T-1 Blue Slave Tank Ill: T-2 Blue Master ❑■ 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: 790.407 ❑ 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: PLLD ❑■ Electronic Line Leak Detector. Model: PLLD ❑■ Tank Overfill / High -Level Sensor. Model: 847390-107 ❑■ Tank Overfill / High -Level Sensor. Model: 847390-107 ❑ 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: T-3 Blue Siphon Tank ID: T-4 Gold ❑ In -Tank Gauging Probe. Model: 847390.107 ® In -Tank Gauging Probe. Model: 847390.107 ❑ Annular Space or Vault Sensor. Model: 794390.407 E 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: PLLD ❑■ Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill / High -Level Sensor. Model: 847390-107 Tank Overfill / High -Level Sensor. Model: 847390.107 ❑ 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 K Dispenser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380.208 0 Shear Valve(s). ❑■ 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 ❑■ Dispenser Containment Sensor(s). Model 794380.208 ❑ Dispenser Containment Sensor(s). Model: 794380-208 ❑ Shear Valve(s). ❑ 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 appy): System set-up ❑■ Alarm history report Technician Name (print): Tim Capehart Signature: Certification No.: 842599 License. No.: 804904 Testing Company Name: Confidence UST Services, Inc. Phone No.: (800) 339-9930 Site Address: 25775 Patterson Pass Road, Tracey, CA 95377 Date of Testing/Servicing: 03/31/2017 Page 1 of 3