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MONIT#RING SYSTEM CERTINT For By W ioiPECENED All Jurisdictions W-thin the State of California rnia Authority Cited.-Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Cod' Ag"WA This form must be used to document testing and Servicing of monitoring equipment. A—sgpdrate certiflic do or form must be provided or. monitoring system control panel by the technician who performs the work. A copy of this =d to- 2"Mat The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test dErl A. General Information Facility Name: SB Gas& Mart Bldg.No.: Site Address: 615West jj'hSt. _ City: Tracy Zip: 96376 Facility Contact Person: Abdul Contact Phone No.: (209) 832-8838 Make/Model of Monitoring System: ICO N TS-1 000-EFI Date of Testing/Servicing: 6/1712010 B. Inventory of Equipment Tested/Certified Check the a ropriate boxes to indicate sloecific equiement insl2ected/serviced: Tank in TI: 87 Tank ID: T2: Diesel 0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging probe, Model: Annular Space or Vault Sensor. Model: EIS 0 Annular Space or Vault Sensor. Model: EIS split tank) L T 0 Check Tank K In-Tank Annular u '-'I c 'D an e a k rC Space Gauging r pa' Sump Piping Sump Trench Sensor(s). Model: ULS 0 Piping Sump Trench Sensor(s). Model: ULS El Fill Sump Sensor(s). Model: n Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: RJ FXIV Mechanical Line Leak Detector. Model: VMI 99 LD-2000 Mechanical o I t Li, Electronic Line Leak Detector. Model: E]Electronic Line Leak Detector. Model: ,- 0 Tank Overfill/High-Level Sensor. Model: ffl Other (,p cif El Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on Page 2). F. F-1 Other(specify equipment type and model in Section E on Page 2). Tank ID- T3: 91 Tank ID: 0 In-Tank Gauging Probe. Model: El In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: El Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: ULS 0 Piping Sump/Trench Sensor(s). Model: [3 Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: VMl 99 LD-2000 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: El Other 1 (specify equipment type and model in Section E on Page 2). 1 0 Other(specify equipment type and model in Section E on Page 2). Dispenser_'_ - ED: 1 &2 Dispenser ID: 3&4 ED Dispenser Containment Sensor(s). Model: Beaudreau 406 0 Dispenser Containment Sensor(s).—Model: Beaudreau 406 Shear Valve(s). 0 Shear Valve(s), ❑Dispenser Containment Float(s)and-Chain(s). 0 Dispenser containment Float(s)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 0 Dispenser Containment Sensor(s). Model: Beaudreau 406 0 Dispenser Containment Sensor(s). Model: 13Gaydreau 406 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). F1 Dispenser Containment Float(s)and Chain(s). 0 Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: Sl [3 Dispenser Co�nZinment Sensor(s). Model: 0 Shear Valve(s). c tS 0 Shear Valve(s). rnDispenser Containment Float(s)and Chain(s). ,in I..t(,l El 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 Alarm history report Technician Name(print): Guadalupe Sanchez Signature: --- Certification No.: 4663613761 — License.No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Phone No.:(209) "S-9586 Testing Company Address: 521 Branding Iron St. Oakdale,CA 95361 Date of Testing/Servicing: 511712010 Page I of 3 Rev(2/08)