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MONI1 ,RING SYSTEM CERTIFIC,-.f ION e c o For Use By All Jurisdictions Within the State of California 1"—1--w— Authority °1--w"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: 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: 10/31/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/seryiced: Tank ID: Tank Ill: ❑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: ❑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). Tank ID: 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: ❑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). Dispenser ID: 13-14 Dispenser-ID: 15-16 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s). Z 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 Cham(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/seryiced 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 applv): ® Systemset-upset-up ®Alarm history report NTechnician Name(print): Nikola Zagorov Signature: tr C>V Certification No.: Veeder Root Level 4#A32784 License.No.: 958763 A NIJ Testing Company Name: ECO-CHEK Compliance Phone No.:(888) 500-CHEK Testing Company Address: P.O. Box 77194, San Francisco CA 94107 Date of Testing/Servicing: 10/31/2013 Page 2 of 6