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May *i`8 11 11:43a Reliable Petroleu 209-845-8953 p.2 0 QNITQRING SYSTEM CERTIFICATION For Use By All Jurisdictions ;Yithin the State of California rtilthority Cited.' Chz wer 6.7. Health and Safety Code; Chapter 16, Division 3, Tilie 23, California Code of Regulations This form must be used to do ument testing and servicing of monitoring equipment. A separate certification or report must he prepared for each monitoring system control pan i by the technician who performs the work. A copy of this form must be provided to the tank system ownerloperator. The owner/operator must subiT t a copy of this form to the local agency regulating UST systems within 30 days of test date. A. Generallnforma n Facility Name: Wilson Ifty Chevron Bldg. 'No.: Site Address: 437 N. Wil on Wa City: Stockton CA Zip: 95205 Facility Contact Person: 1'► ian Mehroke Contact Phone No.: (209) 942-2344 Make/Model of Monitoring ystem: Veeder- Root TLS -350 Date of Testing/Servicing: 2/15/2011 B. Inventory of Equi meet Tested/Certified a.,nccn uicw...v ...... ......�.. ... '—'----------__-.__- Tank 1D: T1:87 Tank ID: T2:91 ® In Tank Gauging Probe. Model: 847390-109 ® in -Tank Gauging Probe. Model: 847390-109 ® Annular Spacc or Vault Senso Model: 794390-407 ® Annular Space or Fault Sensor. Model: 794390-407 ® Piping Sump I Trench Sensor( ). Model: 794380-20B ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Fill Sump Senser(s). Model: 794380-208 ® Mechanical Line Leak Detect _ Modcl: VMI 99LD-2000 01 Mechanical Line Leak Detector. Model: R.J. FX1V ❑ Elo=nic Line Leak l3etecto Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / Hi_h-Level Se sor. Model: ❑ Tani: Overfill / Hi;h-Level Sensor. Model: ❑ Other (specify equipment tyjx and model in Scction E on Page 2). ❑ Other (specify equipment type and model in Section E on Pace 2). TankID: Tank ID: i ❑ In -Tank Gauging Probe. Model: ❑ in -'rank Gauging Probe. Model: ❑ Annular Space or Vault S=SL Model ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump 1 'french Sensor ). Model: ❑ Piping Sump,' Trench Sensor(s). Model: ❑ Fill Sump Sensor(s}. Model: ❑ Fill Sump Selsor(s). Model: ❑ Iviechanical line Leak Detect r. Model: ❑ Mccbanical Line Leak Detector. Model: ❑ Electronic Linz Leak Detecto Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill 'High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment typeand model in Section E on Page 2). ❑Other (specify equipment type and model in Section E on Page 2)• DispenserID: 1&2 Dispenser ID: 3&4 ® Dispenser Containment Sens( (s). Model: 330212-M ® Dispenser Containment Sensor(s). Model: 330212-001 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispcnser Containment Float -) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 ® Dispenser Containment Sans s). Model: 3 30 21 2-00 1 ® Dispense Containment Sensor(s). Model: 330212-001 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Contai nment Float ) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containnten Sens r(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Flo s) and Chain(s). p ❑ Disperser Containment Floats) and Chain(s). flf the facility contains MoreFntcs or atspenscrs, copy ulrS lurin. J11L UUG all 111ML w+ w *• J •u .. •..• , ... Y .••��• • • .••_ •---• C. Certification -I c ify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached o 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 eport, (check all tit at apply): N System set-up Z Alarm history report Technician Name (print): Certification No.: A301 Testing Company Name: Testing Company Addre! Guadalupe Sanchez Signature: License. No.: 883706 Reliable Petroleum Services Inc. PhuuC NU.. (209) 845-8586 11930 Horseshoe Road, Oakdale CA 95361 Date of Testing/Servicing: 211512011 Page 1 of 3 Rev (2.08)