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a . G� ��GG�G MONARING SYSTEM CERT14ATION For Use By All Jurisdictions Within the State of California nnn Authority Cited:Chapter 6.7,Health and Safety Code, Chapter 16, Division 3, Title 23, California CodAyAjag-99P 99 This form must be used to document testing and servicing of monitoring equipment. A separate certification or reMQ&1t monitoring U "t 15 .atern control panel by the technician who performs the work. A copy of this form must be provided to thertMI&& M" crato r. 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: 515w. 11TH Street City: Tracy Zip: 95376 Facility Contact Person: Sanjay Birla Contact Phone No.: (209) 834-8838 Make/Model of Monitoring System: INCON-TS1 000 Date of Testing/Servicing: 511612008 B. Inventory of Equipment Tested/Certified Check the aegroeriate boxes to indicate seecific equiement inspected/serviced: Tank ID: 87 Tank ID: Diesel [I In-Tank Gauging Probe. Model: El In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: INCON EIS Annular Space or Vault Sensor. Model: INCON EIS(SpliL!!2V_ Piping Sump/Trench Sensor(s). Model: INCON ULS Piping Sump/Trench Sensor(s). Model: INCON ULS ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: f-1 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: n Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: nTank 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 Pap 2). Tank 111): 91 Tank ID: *In-Tank Gauging Probe. Model: [I In-Tank Gauging Probe. Model: *Annular Space or Vault Sensor. Model: INCON EIS(split tank) [I Annular Space or Vault Sensor. Model: ED Piping Sump/Trench Sensor(s). Model: INCON ILS n Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: F1 Electronic Line Leak Detector. Model: F1 Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: [I Tank Overfill/High-bevel Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Dispenser ED: 1 &2 Dispenser ED: 3&4 0 Dispenser Containment Sensor(s). Model: Beaudreau 406 Dispenser Containment Sensor(s). Model: Beaudreau 406 [D Shear Valve(s). Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5&6 Dispenser ED: 7&8 •Dispenser Containment Sensor(s). Model: Beaudreau 406 Dispenser Containment Sensor(s). Model: Beaudreau 406 •Shear Valve(s). Shea Valve(s). [I Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment Sensor(s). Model: rl Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). M *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.: A30138 License.No.: 883706 Testing Company Name: RELIABLE PETROLEUM SERVICES INC. Phone No.:(209) 845-8586 Testing Company Address: 621 Branding Iron St. Oakdale Ca.95361 Date of Testing/Servicing: 511612008 Page I of 3 Rev(2/08)