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Jun 1413 12:1Op Reliable Petroleum 2098458953 p.2 ► u MONITORING SYSTEM CERTIFICATION For U.ve By Ali Jurisdictions Within the State of Calrjornia Authority Cited: Chapter 6.7,Health and Safety Code;Chapter 16, Division 3, Title 23, CalOrnia Code oj'Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be orepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank syst%,n 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: Arco Bldg No.: Site Address: 1711 E. Yosernite Ave. City: Manteca Zip: 95336 Facility Contact Person: Sonnie Contact Phone No.: (209)451-8441 hlake/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 312212013 B. Inventory of!Equipment Tested/Certified Check the appropriate boxes to indicate s See ui meat ins ected/serviced: Tank ID: T1: 87 Tank ID: T2: 89 ®In-Tank Gauging Probe. Model: 847390-109 Z In-Tank Gauging Prnhc. :vtodel: 847390-109 ®Annular Space or Vault Sensor. Model 794390-409 Z Annular Space or Vault Sensor. Model: 794390-409 ®Piping Sump/Trench Sensor(s). Model: 794380-323E Piping Sump/Trench Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-323 ®Fill Sump Sensor(s). Model: 794380.323 ®Mechanical Line Leak Detector, Model: FE STP-MLD ®Mechanical Line Leak Detector. Modei: 99LD-2000 ❑Electronic Line Leak Detector. Model: ❑Eleetronic Linc Leak Detector. Model: �I ❑Tank Overfill/High-Level Sensor. Model ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section;E on Paget--)•� ❑Other(s ci equipment pe fytype and model in Section E on Page 2). - Tank ID: T3: 91 Tank ID: Z in-Tani:Gauging Probe. Model: 847390-109 ❑;n-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390-409 ®Piping Sump/Trench Sensor(s). Model: 794380323 ❑Annular Space or Vault model: ❑Piping Sump 1 Trench SensoTnsor(s(&). Model: Fill Sump Sensor(&). Model: 794380.323 ❑Fill Sump Sensor(s). Model: B Mechanical Line Leak Detector. Model: 99LD-2000 ❑Mechanical Line Leak Detector. Madel: []Electronic Line Leak Detector. Model.- ❑Electronic Line Leak Detector. Model: ❑Tank Overfilt/High-Level Seosor. Model: ❑i ank Overfill/Hig%-Levei Sensor. Model: ❑Other(specify equipment.type and model in Section E on Page 2). ❑Other specify equiamcat type and model in S!Ecpn2). Dispenser ID: 1&2 Dispenser ID: 3&4 i Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 ®Shear Valve(s). IZ Shear Valve(s). ❑Dispenser Containment Floats)and Chafn(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 ®Dispenser Containment Scnsor(s). Model: 794380-323 ®Dispenser Containment Sensor(s). Model: 794380-323 ®Shear Valve(s)' ®Shear Valve(&). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: 9&10 ; 19&12 Dispenser ID: 13&14 ; 15&16 ®Dispenser Containment Scasor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model 794380323 ®Shear Valve(s). Z Shea 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 t}'. 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 equr meat capable of generating such reports.!have also attached a copy of the report;(check all that apply): ®System set-up Alarm his ry report Technician Name(print): Guadalupe Sanchez Signatur Cerification 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: 312 212 0 9 3 Page 1 of 4 Rev(2108)