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t RECEIY MONITORING SYSTEM CERTIFICATION P(�, For Use By All Jurisdictions Within the State of California NOV 14 2016 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 se arate certificatioa MWM M9WA&DkEALJaK monitoring system control panel by the technician who performs the work. A copy of this form must be p vie to t�t,�c,c�tgrprer/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of to �'/1Fi I Ivl e A. General Information Facility Name: ARCO Bldg.No.: Site Address: 550 W.Valpico Road City: Tracy,CA Zip: 95376 Facility Contact Person: Edgar Rizkalli Contact Phone No.: (925) 548-7910 Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 10/26/2016 B. Inventory of Equipment Tested/Certified Check the appropfiate boxes to indicatespecific equipment inspected/serviced: "lank Ill: #1 87 20 000 Gal -rank Ill: #2 91 12 000 Gal ®In-Tank Gauging Probe. Model: MAG-1 ®In-Tank Gauging Probe. Model: MAG-1 ®Annular Space or Vault Sensor. Model: 794380-301 ®Annular Space or Vault Sensor. Model: 794380-301 ®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: VR Series 8484 ®Electronic Line Leak Detector. Model: VR Series 8484 ®Tank Overfill/High-Level Sensor. Model: VR Overfill Alarm ®Tank Overfill/High-Level Sensor. Model: VR Overfill Alarm ®Other(specify equipment type and model in Section E on Page 2). Z Other(specify equipment type and model in Section E on Page 2). Tank ID: #3 Diesel 10 000 Gal Tank ID: ®In-Tank Gauging Probe. Model: MAG-1 ❑ In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794380-301 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Senors). Model: 794380-208 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: VR Series 8484 ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: VR Overfill Alarm ❑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: 3-4 ®Dispenser Containment Sensor(s). Model: 794380-208 Z 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: 5-6 Dispenser ID: 7-8 Z Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Senors). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 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 Z Alarm history report Technician Name(print): Nik Zagorov Signature: N?:et% ro✓ Certification No.: Veeder Root Level 4#A32784 License.No.: 958763 A Testing Company Name: ECO-CHEK Compliance,Inc. Phone No.:(888) 500-CHEK Testing Company Address: P.O. Box 1394, Lafayette,CA 94549 Date of Testing/Servicing: 10/26/2016 Page 1 of 6 Rev(2/08)