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" MONIORING SYSTEM CERTIF*TION 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. fhe 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: BOYETT/VALERO BP29 Rprin n r[f idg1N1.-?012 Site Address: 1137 W LATHROP City: MANTECA CA Zip: 95337 Facility Contact Person: Contact Phone No.: (209) 824-2760 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 10/11/2012 B. Inventory of Equipment Tested/Certified Check the appropriate bores to indicatespecific equipment ins ected,sen iced: Tank ID: 87 Tank ID: 91 Z in-Tank Gauging Probe. Model: VEEDER ROOT ®In-Tank Gauging Probe. Model: VEEDER ROOT Z Annular Space or Vault Sensor. Model: 794390-420 ®Annular Space or Vault Sensor. Model: 794390-420 Z Piping Sump/Trench Sensor(s). Model: 794380-208/304 ®Piping Sump/Trench Sensor(s). Model: 794380-208/304 Z Fill Sump Sensor(s). Model: 794380-208/304 ®Fill Sump Sensor(s). Model: 794380-208/304 ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: PLLD Z Electronic Line Leak Detector. Model: PLLD Z Tank Overfill/High-Level Sensor. Model: VEEDER ROOT Z Tank Overfill/High-Level Sensor. Model: VEEDER ROOT ❑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: DIESEL Tank ID: Z In-Tank Gauging Probe. Model: VEEDER ROOT ❑ In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390-420 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-208/304 ❑ Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-208/304 ❑ Fill Sump Sensor(s). Model: ]Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: VEEDER ROOT ❑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: 1/2 Dispenser ID: 7/8 Z Dispenser Containment Sensor(s). Model: 794380-208/304 Z Dispenser Containment Sensor(s). Model: 794380-208/304 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3/4 Dispenser ID: 9/10 Z Dispenser Containment Sensor(s). Model: 794380-208/304 Z Dispenser Containment Sensor(s). Model: 794380-2081 304 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 11/12 Z Dispenser Containment Sensor(s). Model: 794380-208/304 Z Dispenser Containment Sensor(s). Model: 794380-208 / 304 Z Shear Valve(s). Z 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 ®.Alar story report Technician Name(print): GARY HARRIS Signature: Certification No.: B34050 / 5248960-UT License.No.: 779267 Vesting Company Name: L.0 SERVICES Phone No.:(559) 444-1730 f esting Company Address: 3887 N VALENTINE FRESNO CA 93722 Date of Testing/Servicing: 10/11/2012 Page 1 of 3 Rev(2/08)