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Monitoring System Equipment 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 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/6perator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. 'k"`"- A. General Information JUL 2 5 2011 Facility Name:Arco Am Pm Bldg.No.: Site Address: 1100 S. Main St `•N•10% 1-" COu�i y: Manteca, CA Zip: 95337- it-Mvir-PIMMEN L Facility Contact Person: Managera,LTH C1=PA?,TMENT Contact Phone No.: (209)825-6784 Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 6122111 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment Inspected/serviced: Tank[D•01-Regu Tank [Dm 02-Pius ® In-Tank Gauging Probe. Model: VR 847390-109 ® In-Tank Gauging Probe. Model: VR 847390.109 ® Annular Space or Vault Sensor. Model: VR 794390-409 ® Annular Space or Vault Sensor. Model: VR 794390-409 ® Piping Sump\Trench Sensor(s). Model: VR 794380.323 ® Piping Sump\Trench Sensor(s). Model: VR 794380.323 ® Fill Sump Sensor(s). Model: VR 794380-323 ® Fill Sump Sensor(s). Model: VR 794380-323 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Cl Tank Overfill\High-Level Sensor. Model: — [3 Tank Overfill\High-Level Sensor. Model: C3Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). an ID- 03-Prem Tank ID• 2 In-Tank Gauging Probe. Model: VR 847390-109 ❑ In-Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: VR 794390409 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Model: VR 794380-323 ❑ Piping Sump Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: VR 794380-323 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ 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- 01.06 Dispenser W, 02.05 ® Dispenser Containment Sensor(s). Model: VR 794380.323 IS Dispenser Containment Sensor(s). Model: VR 794380-323 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 03-04 Dispenser[D: 07.12 ® Dispenser Containment Sensor(s). Model: VR 794380.323 ® Dispenser Containment Sensor(s). Model: VR 794380-323 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID* 08-11 Dispenser ID- 09.10 ® Dispenser Containment Sensor(s). Model: VR 794380-323 ® Dispenser Containment Sensor(s). Model: VR 794380-323 ❑ 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/seniced In accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'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; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print): Bryan Lundien Signature: Mfg.Cert.#.: B36094 ICC# 8001468-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 6122111