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7 <br /> SYSTEMMONI*PJNG TIF N ® C FEVED <br /> For Use By All Jurisdictions Within the State of California <br /> Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Codi of Regulations <br /> This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must p e Weach <br /> monitoring§ystem control panel by the technician who performs the work. A copy of this form must be provided to the owner/operator. <br /> The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test d IR LENT H ALTH C <br /> A. General Information PERMIT/SERVICES <br /> Facility Name: GAS DEPOT 2 Bldg.No.: <br /> Site Address: 1330 E.Yosemite Ave. City: Manteca Zip: 95336 <br /> Facility Contact Person: Seung Yong Hur Contact Phone No.: (209) 825-0332 <br /> Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 12/10/2007 <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicatespecific c ui ment inspected/serviced: <br /> Tank iD: TI : Regular Unleaded Tank ID: T2 ' Premium Unleaded <br /> ®In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: <br /> Annular Space or Vault Sensor. Model: 794390-409 Annular Space or Vault Sensor. Model: 794390-409 <br /> Piping Sump/Trench Sensor(s). Model: 794380-352 Piping Sump/Trench Sensor(s). Model: 794380-362 <br /> Fill Sump Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 <br /> Mechanical Line Leak Detector. Model: 99LD-2000 ®Mechanical Line Leak Detector. Model: 99LD-2000 <br /> ®Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: <br /> ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: <br /> ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). <br /> Tank ID: T3 : Diesel Tank ID: <br /> ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: <br /> Annular Space or Vault Sensor. Model: 794390-409 ❑Annular Space or Vault Sensor. Model: <br /> Piping Sump/Trench Sensor(s). Model: 79-4380-352 El Piping Sump/Trench Sensor(s). Model: <br /> Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: <br /> Mechanical Line Leak Detector. Model: LD-2000 El Mechanical Line Leak Detector. Model: <br /> Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: <br /> ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: <br /> ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). <br /> Dispenser ID: 1 &2 Dispenser ID: 3&4 <br /> ®Dispenser Containment Sensor(s). Model: 794380-322 ®Dispenser Containment Sensor(s). Model: 794380-322 <br /> Shear Valve(s). Shear Valve(s). <br /> ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: 5&6 Dispenser ID: 7&8 <br /> Dispenser Containment Sensor(s). Model: 794380-322 Dispenser Containment Sensor(s). Model: 794380-322 <br /> Shear Valve(s). ®Shear Valve(s). <br /> ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: 9&10 Dispenser ID: 11 & 12 <br /> Dispenser Containment Sensor(s). Model: 794380-322 Dispenser Containment Sensor(s). Model: 794380-322 <br /> Shear Valve(s). ®Shear Valve(s). <br /> ®Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also <br /> attached a copy of the report;(check all that apply): ED System set-up Alarm history report <br /> Technician Name(print): Guadalupe Sanchez Signature: <br /> Certification No.: A30138 License.No.: 883706 <br /> Testing Company Name: Reliable Petroleum Services Inc. Phone No.:(209) -8586 <br /> Site Address: 521 Branding Iron St. Oakdale Ca.95361 Date of Testing/Servicing: 12/10/2007 <br /> Page 1 of 3 <br />