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MON NG SYSTEM CERTI,ATION For Use By All Jurisdictions Within the State of C jornia A'I thorny Cited: Chapter 6.7 Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each 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. A. General Information Facility Name: Gas Depot 2 Bldg. No.: Site Address: 1330 E. Yosemite Ave. City: Manteca, Ca. Zip: 95336 Facility Contact Person: Kevin Contact Phone No.: (209) 825-0332 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 12/30/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T1: 87 Tank ID: T2: 91 ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 794390-409 ® Annular Space or Vault Sensor. Model: 794390-409 ® Piping Sump / Trench Sensor(s). Model: 794380-352 ® Piping Sump / Trench Sensor(s). Model: 794380-352 Z Fill Sump Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 ® Mechanical Line Leak Detector. Model: 99LD-2000 Z Mechanical Line Leak Detector. Model: 99LD-2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: El Other (specify equipment type and model in Section E on Page 2). El Other (specify equipment type and model in PIT M_ Tank ID: T3: Diesel Tank ID: %W man I v law Lev n In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: IAKI _ y ® Annular Space or Vault Sensor. Model: 794390-409 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 794380-352 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD -2000 ❑ Mechanical Line Leak Detector. Model: OFSH ❑ 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 Z Dispenser Containment Sensor(s). Model: 794380-322 Z Dispenser Containment Sensor(s). Model: 794380-322 Z Shear Valve(s). Z 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 Z Dispenser Containment Sensor(s). Model: 794380-322 Z Dispenser Containment Sensor(s). Model: 794380-322 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9&10 Dispenser ID: 118,12 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-322 Z Shear Valve(s). Z 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, copy this form. 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): ® System set-up ® Alarm histo,py report Technician Name (print): Guadalupe Sanchez Signatur Certification No.: A30138 License. No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.: (209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of Testing/Servicing: 12/30/2014 Page 1 of 4 Rev (2/08)