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MONITORING SYSTEM CERTIFICATION 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: Arco 6080 Bldg.No: Site Address: 85 Louise Ave City: I Lathrop Zip: 95330 Facility Contact Person: Rahim Contact Phone No.: 209-983-9144 Make/Model of Monitoring System.. Veeder Root TLS 350 Date of Testing/Servicing: 1 8-24-10 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: Tank 1 Unleaded Tank ID: Tank 2 Mid rade ®In-Tank Gauging Probe. Model: 847390 ®In-Tank Gauging Probe. Model: 847390 ®Annular Space or Vault Sensor. Model: 794380-302 ®Annular Space or Vault Sensor. Model: 794380-302 ®Piping Sump/Trench Sensor(s). Model: VR 323 ®Piping Sump/Trench Sensor(s). Model: VR 323 ®Fill Sump Sensor(s). Model: VR 323 ®Fill Sump Sensor(s). Model: VR 323 ®Mechanical Line Leak Detector. Model: RJ65 ®Mechanical Line Leak Detector. Model: RJ65 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: 790091-001 ®Tank Overfill/High-Level Sensor. Model: 790091.001 ❑Other s ecif a i ment a and model in Section E on Page 2). ❑Other(s2ecify equipment type and model in Section E on Page 2). Tank ID: Tank 3 Premium Tank ID: ®In-Tank Gauging Probe. Model: 847390 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794380-302 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: VR 323 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: VR 323 ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: RJ65 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: 790091-001 ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment a and model in Section E on Page 2). ❑Other(specify equipment ty e and model in Section E on Dispenser ID: 1/2 Dispenser ID: 3/4 ®Dispenser Containment Sensor(s). Model: 794390-323 ®Dispenser Containment Sensor(s). Model: 794390-323 ®Shear Valve(s). ❑Check if no shear valves are present ® Shear Valve(s). ❑Check if no shear valves are present ❑Dispenser Containment Float(s)and Chain(s). ®NA ❑Dispenser Containment Float(s and Chain(s). ®NA Dispenser ID: 5/6 Dispenser ID: 7/8 ®Dispenser Containment Sensor(s). Model: 794390-323 ®Dispenser Containment Sensor(s). Model: 794390-323 ®Shear Valve(s). ❑Check if no shear valves are present ®Shear Valve(s). ❑Check if no shear valves are present ❑Dispenser Containment Float s)and Chain(s). ®NA ❑Dispenser Containment Float(s)and Chain(s). ®NA Dispenser ID: I Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Check if no shear valves are present ❑Shear Valve(s). ❑Check if no shear valves are present ❑Dispenser Containment Float(s)and Chain s). ❑NA ❑Dispenser Containment Float(s)and Chain(s). ❑NA *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dis enser 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 app/y): ®System set-up ® Alarm history report Technician Name(print): Don Hicks Signature: ap�a- �, nxz Certification No.: A25125 License No.: 300345 Testing Company Name: Wayne Perry Inc. Phone No.: 916-646-9680 Site Address: Street: 85 Louise City: Lathrop Zip: 95330 Date of Testing/Service: 8-24-10 Page I of 4