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Mar 25 13 10:53a Reliable PetroleurnA 209-845-8953 p.2 MONITORING SYSTEM CERTIFICATION For LISV B .old dur' Iia:ta Y id s tat "thin Me,State 01 Cud,�arr��ra AarOkwity Cited' ha Ner 6 9, Health and Safes' Com' C opter IG, Division.i, Title 13, C'arif?urtiQ Caufe Th1s form must be used docuracnt testti»g and servicing of monitoring eouipment n r 1 ' by tine technician uito performs the work. A copy of this farmmust be provided to d c tanl The w,rnerloparatcsr musts mit 8 cApy of this faun to the load agency regulatitig UST systems within 30 days Of tent date. A. Genera[ Informtion Facility Name: Count Site Address: 1856 Ca FaICWty Coataet Pca'son: Make/Model of Monitor B. Inventory of Tack 11D. 91 In -Tan& (iaaging Probe. Annulw Spm or Vaatt se 0 Ageing Sump i Trench Seri Q Fill Sump Sanso qs). ® Mechanical Line Leak beta © Elcz vnic Line teak Dc[ec [I Tank Ovafitl t High -Level © {that (swft eoaWment o Tsmk IV. - 0 In -Tank gauging Probe. Z2 Annular Spare or Vault Se ® Piping smelt 1 Trench San Cl Fill Sump sensw(b), Q Mechanical Line Leak net El Electronic Une Leak Dew C Tank Ovemil 1 fikh-Level O Other(swiN ecuimmm t Dispenser W. 13,2 Q Ctispenser Cootaino�rrt ® Shaar TVatvc(a). ® Dispcnscrcontainment er IA: ® Dispenser Comimtaenc Q Shear Valve(s)— [3 D6pmw CgMmvmret, Dispecr ID: ® mpenser contaimmix 0 Shear Yalve(s) Q Dispcasor ceo sin "if the facility enr"lno City: of Corrtact Phone No.: System: Veeftr Rota TLS -35o Dateof Te )meat Tested]CertWied r. Modal: 79439o.407 jfflt tank t). dlodel: 6-209 Nortel: C. Model: RJ FXIV Model: nsor. Mudd: and ancdol inn Sectim E on Page 2). Model: Model: c}. Model:: Metier r. Modek Model: Kdr Model and rno'& in Scatic a E on Pane 2l. Model: - Model: -- and Chaan(s), Model: rrapuRi andChsin(sj more t ks or dap Mc py C. Certiiicatioa - I mAnaaPaeturere guidel information is con*ct reports, I have also Xft Tedmician Name (print): Certification No.: A30131 Testing Company Name: Testing, Company Address: Tank ID: T2: 87 ❑ In --Tack 4auging Prone, Model: 0 Annular Space err Vault Senior. Motkt ® Piping Sump t i mnch s), Model: 0 Fill sump scrtw(s), Model: 0 McGhadod Litre Leak Detccw. modVI: ❑ Electronic Line Leak DeteCWL Model: ❑ Tank ovicefiff t High-! eve! Sensor. modet 0 Onter (specify equipment tope and medd in Took ID: ❑ In -Tank Ganging 'Probe. Model: ® Annolarspace or Vann Sensor. Model: 11 P P'ng Sump f Trench Sensor(s), Model: ❑ Fill Sump Scnsor(s). Modal: ® Mechmticd We Leak 0mccxr. Model: Q Electronic Line Leak Detector. MW . . ® Tank OvafT ! High -Level Sonsm WOM. d Other (specify cguiprneot type and mark! in S Dispenser ID: 394 DisP�ser Contain Sensor(s)~ A.todel: ® Shear Valve(a), ' ® DisPenw Cmntainrnvet Floats) and Chau(,), Dispemer ID: Q Dispensa Ctmlainmert Se wor(s). Model: 0 Shear Vaive(s)• - ® Dispenser Contairment Fioagsi and cbainrs), Dispenser ®: O C ardsinmcM Sensor(s). Model: ❑ Shear Valve(sj ❑ DfSP—W Carrtairnm at Fleal(s) and Cha*,). efumaation fFot even tank and dispmscr at the owimfoperator. No,: ip: 96204 Ki 212512013 ifY that the CquiplOnt ideutifed in this decurecot sass Ins iservice�d in ccardaace with the PlatAftcplan to Ce inFw -*Ioo (e g- rnarn®fatterers, checklists) neces ry to verify that this s 1Plot Plan showheg tiers laYOW of muni equipment. F'or tiny equipment cepa le of generating such I at copy of the r (ckeck ott tinterPt.. 0 System set-up Alarm Iii tory report lld Sanchez ciono.,..m /_ _ _ a %� y - License. No.: 883706 vices, Irte. Phone No.. ()akt laK Ca.9S361 Date of Piga 1 of 4 212&=13 Rev (mg)