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a MONIT&ING SYSTEM CERTIFTORTION 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 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: SB Gas and Market Bldg.No.: Site Address: 515 . 11"'St. City: Tracy Zip: 95376 Facility Contact Person: Abinash Sharma Contact Phone No.: (209) 834-8838 Make/Model of Monitoring System: INCON TS-1000EFI Date of Testing/Se il : 5/16/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ific equipment ins ected/serviced: 1115, Tank ID: T1: 87 Tank ID: T2: Diesel VVII U J ZOIJ ❑In-Tank Gauging Probe. Model: ❑in-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: INCON EIS ®Annular Space or Vault Sensor. Model: IN ®Piping Sump/Trench Sensor(s). Model: INCON ULS ®Piping Sump/Trench Sensor(s). Model: INCO CES ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: RJ FX1 V ®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: VM199LD-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 ®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: 5&6 Dispenser ID: 7&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 equi meat. 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.: 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: 5/16/2011 Page 1 of 4 Rev(2/08)