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MONIT(#NO SYSTEM CERTIFIC BION 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 lations VED This form must be used to document testing and servicing of monitoring equipment. A separate certification or re ort mus b e 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. MAY 0 3 2012 A. General Information • ENVIRONMENTAL HEALTH Facility Name: Arco Bldg.NoPERMIT4SERWCES Site Address: 1711 E.Yosemite Ave. City: Manteca Zip: 95336 Facility Contact Person: Sonnie Contact Phone No.: (209) 451-8441 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 3/27/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates cific a ui ment inspected/serviced: Tank ID: T1: 87 Tank ID: TZ: 89 ®In-Tank Gauging Probe. Model: 847390-109 Z In-Tank Gauging Probe. Model: 847390-109 ®Annular Space or Vault Sensor. Model: 794390-409 Z Annular Space or Vault Sensor. Model: 794390-409 Z Piping Sump/Trench Sensor(s). Model: 794380-323 Z Piping Sump/Trench Sensor(s). Model: 794380-323 Z Fill Sump Sensor(s). Model: 794380-323 Z Fill Sump Sensor(s). Model: 794380-323 Z Mechanical Line Leak Detector. Model: FE STP-MLD Z Mechanical Line Leak Detector. Model: 99LD-2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Tank Overfill/Hi -Level Sensor. Model: F-1TankOverfill/High-Level Sensor. Model: [ISI► ❑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: Z In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390-409 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-323 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(Q. Model: E Mechanical Line Leak Detector. Model: 99LD-2000' ❑Mechanical Line Leak Detector. Model: j Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑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). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 182 Dispenser ID: 384 Z Dispenser Containment Sensor(s). Model: 794380-323 E Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 586 Dispenser ID: 788 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). E Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9810 ; 11812 Dispenser ID: 13&14 ; 15816 E Dispenser Containment Sensor(s). Model: 794380-323 E Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). E 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 histo re ort Technician Name(print): Guadalupe Sanchez Signatur„g;/�i Certification No.: A30138 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: 3/27/2012 Page 1 of 4 Rev(2/08)