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MONING SYSTEM CERTIF191ATION 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 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. A. General Information Facility Name: B.P.ARCO Bldg.No.: Site Address: 5469 Wilson Way City: Stockton Zip 95205 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: December 26,2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: # Regular Unlead 87 North Tank Tank ID: Regular Unlead 87 South Tank In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ( )Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ( )Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: _ J rill Sump Sensor(s). Model: ( )Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: !]Electronic Line Leak Detector. Model: PLLD D Electronic Line Leak Detector. Model: CPT ❑ 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 a ui ment a and model in Section E on Pae 2). Tank ID: #Super Unlead 91 Center Tank Tank ID: ( )In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment ty e and model in Section E on Page 2). ❑ Other(specify equipment ty e and model in Section E on Page 2). Dispenser ID: Dispenser ID: O 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). 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). i '� ` Dispenser Contamrne::Floats)and Chzin(s). _ y� *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dipenser 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): Eric Molgaard Signature.: Eric Mo(gaard Certification No.: Veeder-Root AZ7995,VMI 1277,ICC Tech 525020OUT License No.: 309105 Testing Company Name:STOCKTON SERVICE STATION EQUIPMENT CO.INC. Phone No 209-464-8333 Site Address: 5469 Wilson Way Date of Testing/Servicing: December 26,2007 Page I of 3 03/01