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MONI SYSTEM CERTIFIWTION For Use By All Jurisdictions Within the State of CaliforniaC 2012 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California C e lations �IvT This form must be used to document testing and servicing of monitoring equipment. A separate certification or re ort lfm-` monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system o or.$ 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: 8/30/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T1: 87 Tank ID: T2: 91 0 In -Tank Gauging Probe. Model: 8473-000-109 In -Tank Gauging Probe. Model: 8473-000-109 Annular Space or Vault Sensor. Model: 794390.409 ® Annular Space or Vault Sensor. Model: 794390-409 Piping Sump / Trench Sensor(s). Model: 794380-352 0 Piping Sump / Trench Sensor(s). Model: ',{80-352 Fill Sump Sensor(s), Model: 794380-208 ® Fill Sump Sensor(s).M I: , 380-208 ® Mechanical Line Leak Detector. Model: 99LD-2000 Mechanical Line Leak Detector. M' el: D-2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: 1 ❑ 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: T3: Diesel Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: El 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 0 Mechanical Line Leak Detector. Model: El 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: 152 Dispenser ID: 354 ® Dispenser Containment Sensor(s). Model: 794380-322 ® Dispenser Containment Sensor(s). Model: 794380-322 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 556 Dispenser ID: 758 Dispenser Containment Sensor(s). Model: 794380-322 ® Dispenser Containment Sensor(s). Model: 794380-322 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9510 Dispenser ID: 11512 Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-322 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, 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/X") ced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' chec necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equ4 ment capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up Alartff hist eport Technician Name (print): Guadalupe Sanchez Signature e Certification No.: A30138 License. No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.: (2„ ) 845-8586 , Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of Testing/Servicing: 8/30/2012 Page 1 of 4 Rev (2/08)