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u [�� MONUJ�RING SYSTEM CERTIF*kTION C `',V E 0 For s e By All Jurisdictions Within the State of Cali ornia Authority Cited: Chapter 6.7,Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of A4"Pa �a 0 9 This form must be used to document testing and servicing of monitoring equipment. A separate certification or reportm4st,be.'"e aridfor monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/op"q!' 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: SB GAS&MART Bldg.No.: Site Address: 515 W. 11th Street City: Tracy CA Zip: 96376 Facility Contact Person: Abdul Contact Phone No.: (5- 0) 366-9924 Make/Model of Monitoring System. ICN TS 1001 Date of Testing/Servicing: 512912009 B. Inventory of Equipment Tested/Ce rffied Check the appropriate boxes to indicate s i ic c ui ment------"Ierviced: 0 Tank ID: TI: 8#17 Tank w: T2: Diesel [I In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: TSP-EIS 0 Annular Space or Vault Sensor. Model: TSP-EIS(split tank) Piping Sump/Trench Sensor(s). Model: TSP-ULS 0 Piping Sump/Trench Sensor(s). Model: TSP-ULS El Fill Sump Sensor(s). Model: F-1 Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: 171 Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: []Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Tank w: T3:91 Tank ID: 0 In-Tank Gauging Probe. Model: 1-1 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: TSP-EIS El Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: TSP-ULS [I Piping Sump/Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: D Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1 &2 Dispenser ID: 3&4 ED Dispenser Containment Sensor(s). Model: Beand 0 Dispenser Containment Sensor(s). Model: Beaudreau Z Shear Valve(s). I@ Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). [I Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 0 Dispenser Containment Sensor(s). Model: Beaudreau 19 Dispenser Containment Sensor(s). Model: Beaudreau 0 Shear Valve(s). 9 Shear Valve(s). 171 Dispenser Containment Float(s)and Chain(s). [I Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). F-1 Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). 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 get-up 0 Alarm history report Technician Name(print): Guadalupe Sanchez Signatur�e-..,. l, Certification No.: 4563613761 License.No.: 883706 f Testing Company Name: Reliable Petroleum Services Inc. Phone No.:(22�9) 845-8586 Testing Company Address: 521 Branding Iron Street,Oakdale CA 95361 Date of Testing/Servicing: 5129/2009 Page I of 4 UN-036-1/4 www.unidocs.org Rev.01117/08