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ED MONITORING SYSTEM CERTIFICA V 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 C \pf f �ns 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 tot tg*VTA F_P The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 d A. General Information KarAIMUMM Facility Name: Arco # 82602 Bldg. No.: Site Address: _2430 Joe Pombo Pkwy City: Tracy, CA Zip: 95376 Facility Contact Person: Vikram Contact Phone No.: (209) 579-4014 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 10/1912017 B. Inventory of Equipment Tested/Certified /`hn.d, thn ann—viote h— to inA;"ta enaeifin Pnnin,nnnt inenPPtPd/cenriPPde Tank ID: T1: 87 Master Tank ID: T2: 87 Syphon ® In -Tank Gauging Probe. Model: 847390-109 ® In -Tank Gauging Probe. Model: 847390-109 ® Annular Space or Vault Sensor. Model: 794390409 ® Annular Space or Vault Sensor. Model: 794390.409(split tank) ® Piping Sump / Trench Sensor(s). Model: 794380-323 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-323 ❑ 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 ID: T3: 91 Tank ID: ® In -Tank Gauging Probe. Model: 847390-109 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 7943904309(split tank) ❑ 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: 3&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: 6&6 Dispenser ID: 7&8 ® 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: 9&10 Dispenser ID: 11&12 ® 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). *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 Certification No.: A30138 Signatu� er'" License. No.: 1005444 Testing Company Name: Diamond Petroleum Services, Inc. Phone No.: (925) 470-0803 Testing Company Address: 3619 King Ct. Antioch, CA. 94509 Date of Testing/Servicing: 10/19/2017 Page 1 of 4 Rev (2/08)