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MONRING SYSTEM CERTIFWTION RECORD 'Morse By All Jurisdictions Within the State of Cali Iorni . a AUG 13 Z010 Authority Cited: Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code oA.Reaulativ HH EN' U IVItl EAS. This form must be used to document testing and servicing of monitoring equipment. A separate certification or re ort MUMElwago"00–m— monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the Wlk'system " 6wne' 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: Statewide Petroleum Site Address: 1700 E. Yosemite Avenue City: Mantec M«_ Zip: 95336 Facility Contact Person: Randy Singh Contact Phone No.: (209) 628-3300 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 7/20/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate sriecific eqUiDment insnected/serviced: Tank ID: TI: -87 Tank ID: T2:91 In -Tank Gauging Probe. Model: El In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: PA 02591360000 Annular Space or Vault Sensor. Model: 794390-420 ED Piping Sump / Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: VMI LD -2000 Mechanical Line Leak Detector. Model: VMI 99LD-2000 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El Tank Overfill / High -Level Sensor. Model: El Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment type and model in Section E on Page 2). El Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: 0 In -Tank Gauging Probe. Model: El In -Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: F-1 Annular Space or Vault Sensor. Model: El Piping Sump / Trench Sensor(s). Model: El Piping Sump / Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: El Tank Overfill / High -Level Sensor. Model: El Other (specify equipment type and model in Section E on Page 2). 0 Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1 /2 Dispenser ID: 3/4 Dispenser Containment Sensor(s). Model: 794380-208 0 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). 0 Shear Valve(s). Dispenser Containment Float(s) and Chain(s). El Dispenser Containment Float(s) and Chain(s). Dispenser ID: 616 Dispenser ID: 718 0 Dispenser Containment Sensor(s). Model: 794380-208 0 Dispenser Containment Sensor(s). Model: 794380-208 19 Shear Valve(s). 0 Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). El Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). M El Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). H uic i4cuity contains more tanks or dispensers, copy this torm. 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): Z system set-up M Alarm history report Technician Name (print): Guadalupe Sanchez Signature: Certification No.: A30138 License. No.: 883706 Testing Company Name: Reliable Petroleum Service Inc. Phone No.: (209) 846-8586 Testing Company Address: 621 Branding Iron Street, Oakdale CA 95361 Date of Testing/Servicing: 7/2012010 Page 1 of 4 UN -036 -1/s www.unidocsorg Rev. 01/17/08