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M MONIARING SYSTEMCERTIFOATION 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 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 Bldg.No.: Site Address: 2430 Joe Pombo Pwy City: Tracy, Ca. Zip: 95376 Facility Contact Person: Ranjeet Contact Phone No.: (209) 579-4014 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 10/16/2012 B. Inventory of Equipment Tested/Certified PS CP1 Check the appropriate boxes to indicatespecific a !! ment inspected/serviced: Tank ID: T1: 87 Waster Tank ID: T2: 87 Syphon Aln I, ®In-Tank Gauging Probe. Model: 847390-109 In-Tank Gauging Probe. Model: 04 J 2n •Annular Space or Vault Sensor. Model: 794390-409 Annular Space or Vault Sensor. Model. 409 ®Piping Sump/Trench Sensor(s). Model: 794380-323 Piping Sump/Trench Sensor(s). Model: 7AjrA ®Fill Sump Sensor(s). Model: 794380-323 ®Fill Sump Sensor(s). Model: 79438 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: 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). Tank m T3: 87 91 Tank ID: •In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: •Annular Space or Vault Sensor. Model: 794390-409 ❑Annular Space or Vault Sensor. Model: •Piping Sump/Trench Sensor(s). Model: 794380-323 ❑Piping Sump/Trench Sensor(s). Model: •Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®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: 38,4 •Dispenser Containment Sensor(s). Model: 794380-323 Dispenser Containment Sensor(s). Model: 794380-323 •Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 58,6 Dispenser ID: 7&8 Dispenser Containment Sensor(s). Model: 794380-323 ®Dispenser Containment Sensor(s). Model: 794380-323 ED Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Cham(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 98,10 Dispenser ID: 11&12 Dispenser Containment Sensor(s). Model: 794380-323 Dispenser Containment Sensor(s). Model: 794380-323 10 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): System set-up Alarm history report Technician Name(print): Guadalupe Sanchez Signatur • , Certification No.: A30138 License.No.: 883706 ell Testing Company Name: Reliable Petroleum Services, Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd.Oakdale,Ca.95361 Date of Testing/Servicing: 10/16/2012 Page 1 of 4 Rev(2/08)