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A. General Information Facility Name: Arco #5450 Date of Testing/Servicing: August 30, 2012 Facility Address:1617 W. Fremont St., Stockton CA 95203 Facility Contact Person: Karen Facility Phone: 209-462-1617 LIA: San Joaquin County EHD;Inspector:Stacy Rivera;LIA Phone: ; LIA Fax: Make/Model of Monitoring System: Veeder-Root TLS -350 LIA email; srivera@sjcehd.com B. Inventory of Equipment Tested/Certified: Tank ID: T1 Regular Master Tank ID: T2 Regular Syphon ®In -Tank Gauging Probe. Model: Mag 1 ®In -Tank Gauging Probe. Model: Mag 1 ®Annular Space Sensor. Model: 794380-409 ®Annular Space Sensor. Model: 794380-409 ®Piping Sump Sensor(s). Model: 794380-323 P.O. acx �� 4 u 4{{*?,`� a .S?''•�c. ;'�"o'Ce ,. Sonnra CA . ;7. H23541 h -H? -. 1r1:]'te: LS9532 732J ....,. .;?..c... ,.;: ,..{... .;,... ,. z.,+.....;:' Fax: 2G9 ® Fills ill Bucket Tested: ❑Pass ®Fail Tank ID: T3 Premium Tank Tank ID: M', Irs?tilf chprtrr..crsrn ❑In -Tank Gauging Probe. Model: ®Annular Space Sensor. Model: 794380-409 ❑Annular Space Sensor. Model: hl4rtrc.cam l' ❑Piping Sump Sensor(s). Model: ®Fill Sump Sensor(s). Model: 794380-323 MONITORING SYSTEM CERTIFICATION ®Electronic Line Leak Detector. Model: V -R PLLD A. General Information Facility Name: Arco #5450 Date of Testing/Servicing: August 30, 2012 Facility Address:1617 W. Fremont St., Stockton CA 95203 Facility Contact Person: Karen Facility Phone: 209-462-1617 LIA: San Joaquin County EHD;Inspector:Stacy Rivera;LIA Phone: ; LIA Fax: Make/Model of Monitoring System: Veeder-Root TLS -350 LIA email; srivera@sjcehd.com B. Inventory of Equipment Tested/Certified: Tank ID: T1 Regular Master Tank ID: T2 Regular Syphon ®In -Tank Gauging Probe. Model: Mag 1 ®In -Tank Gauging Probe. Model: Mag 1 ®Annular Space Sensor. Model: 794380-409 ®Annular Space Sensor. Model: 794380-409 ®Piping Sump Sensor(s). Model: 794380-323 ®Piping Sump Sensor(s). Model: 794380-323 ®Fill Sump Sensor(s). Model: 794380-323 ®Fill Sump Sensor(s). Model: 794380-323 ®Electronic Line Leak Detector. Model: V -R PLLD ❑ Line Leak Detector. Model: ®Tank Overfill / High -Level Sensor. Model: V -R Audible ®Tank Overfill / High -Level Sensor. Model: V -R Audible ® Fillspill Bucket Tested: ®Pass [-]Fail ® Fills ill Bucket Tested: ❑Pass ®Fail Tank ID: T3 Premium Tank Tank ID: ® In -Tank Gauging Probe. Model: Mag Plus ❑In -Tank Gauging Probe. Model: ®Annular Space Sensor. Model: 794380-409 ❑Annular Space Sensor. Model: ®Piping Sump Sensor(s). Model: 794380-323 ❑Piping Sump Sensor(s). Model: ®Fill Sump Sensor(s). Model: 794380-323 []Fill Sump Sensor(s). Madel: ®Electronic Line Leak Detector. Model: V -R PLLD ❑ Line Leak Detector. Model: ®Tank Overfill / High -Level Sensor. Model: V -R Audible ❑Tank overfill/ High -Level Sensor. Model: N Fillspill Bucket Tested: ®Pass ❑Fail _❑ Fillspill Bucket Tested: []Pass ❑Fail Dispenser ID: 1&2 ® Sump: ®Dry ❑Water [--]Product::: Dispenser ID: 1&4 ®>Sump:,®Dry ❑Water []Product' ® Dispenser Containment Sensor(s). Model: 794380-323 ®Dispenser Containment Sensor(s). Model: 794380-323' ®Shear Valves) Functional test ®Shear Valves Functional test Dispenser ID: 5&6 ® Sump' ®Dry ❑Water ❑Product Dispenser ID:.798 ®'Sump: (Dry ❑Water ❑Product' ®Dispenser Containment Sensor(s). Model: 7943$0-323 ®Dispenser Containment Sensor(s), Model' 794380-323' ®Shear Valves Functional test ®Shear Valves (Functional test C. Certification - 1 certify that the equipmentidentified' in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is 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; ®",System set-up Alarm history report