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m 0 it n 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 prepared for each monitoring system control panel by the technician who perforans 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 fonn to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Arco BP 5450 Site Address: 1617 W Fremont St Cit; Facility Contact Person: Not reported Make/Model of Monitoring System: Veeder Root TLS350 B. Inventory of Equipment Tested/Certified .... -.At.. +. ..In.. -.i.. --i.. of -.t1 -4—A Bldg. No.: Stockton Zip: 95203 Contact Phone No.: (209) 482-1617 Date of Testing/Servicing: 9/23/2010 Tank ID: 87 Main Tank ID: 87 AUX Z In -Tank Gauging Probe. Model: mag probe ® In -Tank Gauging Probe. Model: mag probe Z Annular Space or Vault Sensor. Model: vtr-409 ® Annular Space or Vault Sensor. Model: v/r-409 ® Piping Sump / Trench Sensor(s). Model: vir-323 ® Piping Sump / Trench Sensor(s). Model: v/r-323 ® Fill Sump Sensor(s). Model: v/r-323 ® Fill Sump Sensor(s). Model: v/r-323 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector_ Model: red jacket ept ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: probe ® Tank Overfill / High -Level Sensor. Model: probe ❑ 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: 91 Tank ID: ® In -Tank Gauging Probe. Model: mag probe ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: v/r-409 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: v/r-323 ❑ Piping Sump/ Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: v/r-323 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: VR FXIV ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: probe ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section Eon Page 2). ❑ 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: v/r-323 ® Dispenser Containment Sensor(s). Model: v/r-323 Z Shear Valve(s).opw ® Shear Valve(s). opw ❑ 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: v/r-323 Z Dispenser Containment Sensor(s). Model: v/r-323 Z Shear Valve(s).opw Z Shear Valve(s).opw ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ 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, coov 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 equent capable of generating such reports, I have also attached a copy of the report; (check all that apple'): ❑ System set-up ipmAlarm history report Technician Name (print): Brandon Smith Signature:{ t-? Certification No.: A30746 License. No.: 300345-A HAZ C21 Testing Company Name: Wayne Perry Phone No.: (916) 646-9680 Site Address: 30 Main Ave Sacramento, Ca 95838 Date of Testing/Servicing: 9/23/2010 Page I of 4