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MONI*PJNGCERTIF*kTION 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 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 Site Address: 1330 E. Yosemite Ave. Facility Contact Person: Kevin Hur Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Bldg. No.: City: Manteca Zip: 95336 Contact Phone No.: (209) 825-7722 Date of Testing/Servicing: 6/23/2010 D t(Ds yn; -6) Tank ID: T1: 87 Tank ID: T2: 91 In -Tank Gauging Probe. Model: 847390-109 ® In -Tank Gauging Probe. tlVVIR 1: 84473F906 -"M9 Annular Space or Vault Sensor. Model: 794390-409 ® Annular Space or Vault Sens o lit tank Piping Sump / Trench Sensor(s). Model: 794380-352 Piping Sump / Trench Sensor(s). Fill Sump Sensor(s). Model: 794380-208 _ Fill Sump Sensor(s). Model: 794, Mechanical Line Leak Detector. Model: VMI 99LD-2000 ® Mechanical Line Leak Detector. Model: VMI 99LD-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: T3: Diesel Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390-409 (split tank) ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 794380-352 El Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 794380-208 El Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: VMI LD -2000 El Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: El 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). ❑ 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: 794380-322 Dispenser Containment Sensor(s). Model: 794380-322 El 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: 794380-322 Z 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: 9+10 Dispenser ID: 11+12 ® 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). 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 history report Technician Name (print): Guadalupe Sanchez Signature: Certification No.: A30138 License. No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Phone No.: (209) 845-9657 Testing Company Address: 521 Branding Iron St. Date of Testing/Servicing: 6/23/2010 Page 1 of 3 Rev (2/08)