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ONIT NG SYSTEM CERTIFICWION 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 REGRIVE-"o This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be r ar d 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'o r/ p The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date 1 h1A.AEtV �iL A. General Information PES IT/SE l caS Facility Name: ARCO AM PM Bldg.No.: Site Address: 2430 Joe Pombo Parkway City: Tracy Zip: 95377 Facility Contact Person: Ranjeet Singh Contact Phone No.: (209) 830-8778 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 10/27/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a ui ment inspected/serviced: Tank ID: T1: 87 Master Tank ID: T2: Syphon ®In-Tank Gauging Probe. Model: 109 Z In-Tank Gauging Probe. Model: 109 ®Annular Space or Vault Sensor. Model: 409 E Annular Space or Vault Sensor. Model: 409 1,>. Z Piping Sump/Trench Sensor(s). Model: 323 ®Piping Sump/Trench Sensor(s). Model: 323 ,r Z Fill Sump Sensor(s). Model: 323 ®Fill Sump Sensor(s). Model: 323 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: HE qLrH ®Electronic Line Leak Detector. Model: 8484 ❑Electronic Line Leak Detector. Model: ITS R ❑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: Premium Tank ID: Z In-Tank Gauging Probe. Model: 109 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 409 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 323 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 323 E]Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line 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). Dispenser ID: 1/2 Dispenser ID: 3/4 Z Dispenser Containment Sensor(s). Model: 323 Z Dispenser Containment Sensor(s). Model: 323 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 Dispense'Containment Sensor(s). Model: 323 Z Dispenser Containment Sensor(s). Model: 323 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9110 Dispenser ID: 11112 Z Dispenser Containment Sensor(s). Model: 323 Z Dispenser Containment Sensor(s). Model: 323 Z 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): Z System set-up Z Alarm history report Technician Name(print): Guadalupe Sanchez Signature: Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Rhone No.: 209 845-8586 Testing Company Address: 11930 Horseshoe Road, Oakdale CA 95361 Date of Testing/Servicing: 10/27/2011 Page 1 of 3 Rev(2/08)