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MONIARING SYSTEM CERTIFATION For Use By All Jurisdictions Within the State of California 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 DC4 e r monitoring_system control panel by the technician who performs the work. A copy of this form must be provided to the tank 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 JUL 2 2012 Facility Name: SB Gas and Market ENTAI Site Address: 515 . 11th St. City: Tracy i . 8 I . Facility Contact Person: Abinash Sharma Contact Phone No.: (209) 834-8838 Make/Model of Monitoring System: INCON TS-1000EFI Date of Testing/Servicing: 6/1/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced. Tank ID: T1: 87 Tank ID: T2: Diesel ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: •Annular Space or Vault Sensor. Model: INCON EIS Annular Space or Vault Sensor. Model: INCON EIS(split tank) •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: ®Mechanical Line Leak Detector. Model: RJ FX1V ®Mechanical Line Leak Detector. Model: VMI 99LD-2000 ❑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). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: T3: 91 Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: INCON EIS(split tank) ❑Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: INCON ULS ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model ®Mechanical Line Leak Detector. Model: VMI 99LD-2000 ❑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). ❑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: Beaudreau 406 Z Dispenser Containment Sensor(s). Model: Beaudreau 406 ®Shear Valve(s). 0 Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 58,6 Dispenser ID: 78,8 Dispenser Containment Sensor(s). Model: Beaudreau 406 ®Dispenser Containment Sensor(s). Model: Beaudreau 406 Shear Valve(s). ®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 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 Alarm history report Technician Name(print): Guadalupe Sanchez SignatVW,;—_—.—_�---( * _.L/ Ar Certification No.: 7484063702 License.No.: 883706 Testing Company Name: Reliable Petroleum Services,Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd.Oakdale, Ca.95361 Date of Testing/Servicing: 6/1/2012 Page 1 of 4 Rev(2/08)