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MY 2 SMONIT&ING SYSTEM CERTIFICAT ON A For Use By All Jurisdictions Within the State of California 1,,j ptµt&.�.7,Health and Safety Code:Chapter 16.Division 3. Title 23.Califorrtio(jade of Regulations I EMP ^ This form must be Pi R4W111JbC&C9Y1R g 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 ol'this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: MANTECA ARCO Cou ity: SAN JOAQUIN Site Address: 1711 E YOSEMITE City: MANTECA Facility Contact Person: MVP Contact Phone Make/Model of Monitoring System: TLS350 Date of Testing/Servicing: 5/16/2013 B. Inventory of Equipment Tested/Certified Tank ID: T1 -87-2 Tank ID: T3 87-2 ® In-Tank Gauging Probe. Model: MAG M In-Tank Gauging Probe. Model: NIAG M Annular Space or Vault Sensor. Model: 409 ®Annular Space or Vault Sensor. Model: 409 M Piping Sunnp i'french Sensor(s). Model: 323 M Piping Sump/Trench Sensor(s). Model: 323 M Fill Sump Sensor(s). Model: 208 M Fill Sump Sensor(s). Model: 208 ❑ Mechanical Linc l.cak Detector. Model: El Mechanical Line Leak Detector. Model: M Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: ®Tank Overfill/I ligh-Level Sensor. Model: EXT ALARNI M Tank Overfill/High-Level Sensor, Model: EXT ALARM ❑Other(speeifj equipnnent 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: M In-Tank Gauging Probe. Model: MAG ❑ In-Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: 409 ❑Annular Space or Vault Sensor. Model: M Piping Sump i"french Sensor(s). Model: 323 ❑Piping Sump/Trench Sensor(s). Model: M Fill Sump Sensor(s). Model: 20323 ❑ Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: M Tank Overfill/I ligh-Level tiensor. Model: EXT ALARM ❑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 G on Page 2). Dispenser ID: I/2 Dispenser ID: 3/4 M Dispenser Containment Sensor(s). Model: 323 M Dispenser Containment Sensor(s). Model: 323 M Shear Valve(s). M Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: S/6 Dispenser ID: 7/8 M Dispenser Containment Sensor(s). Model: 323 M Dispenser Containment Sensor(s), Model: 323 ®Shear Valve(s). M 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: I ❑ 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). Check the appropriate boxes to indicate specific equipment inspected/serviced: 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 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 app/y): M System set-up M Alarm history report Technician Name(print): KELVIN CRUZ Signature: , _ C� Certification A22519 License No.: 433159 Testing Company Name: B.Z.Service Station Maintenance Phone No.: (916) 371-2380 Site 1041 Triangle Court West Sacramento,CA 95605 Date of Testing/Servicing: 5/16/2013 Monitoring Certification Test Report 1 of 4