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NOVricueIVE![) 16 2015 MONITORING SYSTEM CERTIFICATION For l 'se By All Jurisdictions Within the State of California 't"RONMENTAL HEALTH Attthorin' C'ited.• Chapter 6.7. Health and Safetp Code: Chapter 16. Division 3. Title 23. California Code gl'Kegulatioi?s PERMMSERVICES This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitc -ing system control panel by the technician who perfbnns the work. A copy of this form must be provided to the tank system owner/operator. The owner/o,=erator must submit a copy of this firm to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: ARCO AMPM Site Address: 880 E VICTOR RD Facility Contact Person: KARAN Make/Model of Monitoring System: TLS350 B. Inventory of Equipment Tested/Certifier) County: SAN JOAQUIN City: LODI Contact Phone 209-369-0958 Date of Testing/Servicing: 9/28/2015 Tank ID: T1-87 Tank ID: T2-91 ® in -Tank Gauging Probe. Model: MAG Z In -Tank Gauging Probe. Model: SIA(; - ® Annular Space or Vault Sensor. Model: 301 ® Annular Space or Vault Sensor. Model: 301 ® Piping Sump /'French Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector, Model: LD2000 _ Z Mechanical Line Leak Detector. Model: LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor, Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). Z Tank Overfill / High -Level Sensor, Model: FLAPPER ❑ Other (specify equipment type and model in Section Eon Page 2 . Tank ID: T3 -DSL Tank ID: Z In -Tank Gauging Probe. Model: NiAG ❑ In -Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: Z Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Tank Overfill / High -Level Sensor. Model: ❑ 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: 208 Z Dispenser Containment Sensor(s). Model: 208 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: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: 9/10 Dispenser ID: Z Dispenser Containment Scnsor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floatls) and Chain(s). Check the annrnnriutp h.— r„ .* , 1; -f_ .. :e Pee. C eoulpuncntonspecteurservicea: 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 r rifv that this information is correct and a Plan showing the layout of monitoring equipment. For any equipment capable of generr king such reports, I have also attached a copy of the report; (check all that apply): Z System set-up E Alarm histo y rel+ort Technician Name (print): RHOME DESBIENS Signature: Certification A22883 License No.: 433159 Testing Company Name B. Z. Service Station Maintenance Phone No.: (916) 371-2380 Stte 1041 Triangle Court West Sacramento, CA 95605 Date of Testing/Servicing: 9/28/2015 Monitoring Certification Test Report I of 5