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Rev (2/08) MONITORING SYSTEM CERTIFICATION 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 pEmgmd 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: Arco #2130 Bldg. No.: Site Address: 7906 N EI Dorado City: Stockton Zip: Facility Contact Person: Site Attendant Contact Phone No.: (209) 957-2987 Make/Model of Monitoring System: TLS -3501 Veeder Root Date of Testing/Servicing: 10/19/2009 B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to indicate specific equipment ins serviced: Tank im TI -87 Tank ID: T2-87 ® In -Tank Gauging Probe. Model: 847390-109 ® in -Tank Gauging Probe. Model: 847390-109 N Annular Space or Vault Sensor. Model: 794390-409 ® Annular Space or Vault Sensor. Model: 794390-409 ® Piping Sump / Trench Sensm(s). Model: 794383-323 ® Piping Sump / Trench Sensor(s). Model: 794380-323 ® Fill Sump Sensor(s). Model: 794383-323 ® Fill Sump Senor(s). Model: 794380-323 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Lice Leak Detector. 'Model: 8484 ❑ 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: T3-87 Tank iD: T4-91 ® In -Tank Gauging Probe. Model: 847390-109 ® In -Tank Gauging Probe. Model: 847390-109 Annular Space or Vault Sensor. Model: 794390409 0 Annular Space or Vault Senses. Model: IN Piping Su / TrenchSensor(s). Model: 380-323 1@ Piping S / Trench s). Model: 794380-323 Fill S s). Model: 794380-323 0 Fill Sump Sensor(s). Model: 7 ❑ Mechanical Lime Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 8484 0 Electronic Line Leak Detector. Model: ❑ Tank Overfill / Higb-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 m: #112 Dispenser ID: #314 ® Containment Sensor(s). Model: 794380323 ® Dispenser Containment Sensor(s). Model: 794380-323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Disposer Containment Float(s) and Chain(s). Dispenser ID: #M Dispenser ID: #718 ® Dispenser Containment Sensor(s). Model: 794380-323 ® Dispenser Containment Sensor(s). Model: 794380-323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Contaminant Float(s) and Chain(s). ❑ Disposer Containment Float(s) and Chain(s). Dispenser ID: Dispenser TD: ❑ Disperser Containment Sensor(s). Model: ❑ Dispenser Containment Sersor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Conwinmimt Float(s) and Chain(s). ❑ Dispenser Containment Fko9s) 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 (eg. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equi meat. For any equipment capable of generating such reports, I have also attached copy the that System Alarm history a of report; (check all ): set-up report Technician Name (print): Joe Sema Signature: Certification No.: A30455 License. No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: (925) 551-4777 Testing Company Address: 6747 Sierra CL, Dublin, Ca Date of Testing/Servicing: 10119/2009 Page 1 of 3 Rev (2/08)