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I IR MONIORING SYSTEM CERTIFOATION MN For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Cn}jq��sll� This form must be used to document testing and servicing of monitoring equipment. A separate certification or repord'f 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. MAR 2 4 2008 A. General Information Facility Name: YOSEMITE 76 Site Address: 1700 Yosemite Ave. r City: Manteca Ca. Zip: 95336 Facility Contact Person: Terry Dosanjh Contact Phone No.: (209) 823-7676 Make/Model of Monitoring System: Veeder Root Date of Testing/Servicing: 3/18/2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T1: 87 Octane Tank ID: T2: 91 Octane ❑ In -Tank Gauging Probe. Model: El In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: PA02591360000 Annular Space or Vault Sensor. Model: 794390-420 Piping Sump / Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: VMI 2000 ® Mechanical Line Leak Detector. Model: VMI 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ 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 E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ 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 E on Page 2). Dispenser ID: '1+2 Dispenser ID: 3 + 4 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5 + 6 Dispenser ID: 7 + 8 Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). ® 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: ❑ 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). *If the facility contains more tanks or dispensers. coov this form. Include information for every tank and disnenser 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): System set-up Alarm history report Technician Name (print): Guadalupe Sanchez Signa Certification No.: A30138 License. No.: 883706 Testing Company Name: RELIABLE PETROLEUM SERVICES INC. Phone No.: (209) 845-8586 Testing Company Address: 521 Branding Iron St. Oakdale Ca. 95361 Date of Testing/Servicing: 3/18/2008 Page 1 of 3 ,r Rev (2/08)