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MONPORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the S1ale of California Authority Cited• Chapter 6.7. Health and Safely 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- svgem 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 lorm to the local agency regulating USD' 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: 10/21/2015 B. Inventory of Equipment Tested/Certified Check thea rcr riate boxes to indicate specific a ui ment ins cted/serviced: Tank iD: T1: 87 Master Tank ID: T2: 87 Siphon ® In -Tank Gauging Probe. Model: 847390-109 ® In -Tank Gauging Probe. Model: 847390-109 ® Annular Space or Vault Sensor. Model: 794390-409 ® Annular Space or Vault Sensor. Model: 794390-409(split tank) ® Piping Sump /Trench Sensor(s). Model: 794380-323 ® Piping Sump /Trench Scnsons). Model: 794380-208 ® Fill Sump Sensors). Model: 794380-323 ® Fill Sump Sensor(s). Model: 794380-323 ❑ Mechanical Line Ixak Dcaector. Model: ❑ Mechanical Linc Leak Detector. Model: ® Electronic Linc Leak Detector. Model: 8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill i High-level Sensor. Model: ❑ 'Dank Ovcrl ill / I ligh-Level Sensor. Model: ❑ Other (specify equipment type and model in Section F on Page 2). ❑ Other (specity equipment type and model in Section F on Page 2). Tank ID: T3' 91 Tank ID: 7w -- ® In -Tank Gauging Probe. Model: 847390-109 ❑ In= Tank Gauging Probe. 'f ® Annular Space or Vault Sensor. Model: 794390-409(split tank) ❑ Annular Space or Vault Sensor. c ® Piping Sump /Trench Sensor(s). Model: 794380-323 ❑ Piping Sump t Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 794380-323 ❑ Fill Sump Sensor(s). Mod J 2 jji5 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Linc Leak Detector. Model: ® Electronic Line Leak Detector. Model: 8484 ❑ fileetronic i.ine Irak Detector. ❑ Wank Overfill / High -Level Sensor. Model: ❑ Tank Overfill/ High -Level Sensor. t>A[tiZru nGpAOTaA jd-f ❑ 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 Scnsor(s). Model: 794380-323 ® Dispenser Containment Sensor(s). Model: 794380-323 ® Shear Valvas). ® 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 ® Dispenser Containment Sensor(s). Model: 794380-323 ® Dispenser Containment Sensor(s). Model: 794380-323 ® Shear Valve(s). ® Shear Valvas). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser 1D: 9&10 Dispenser ID: 11&12 ® Dispenser Containment Sensor(s). Model: 794380-323 ® Dispenser Containment Sensor(s). Model: 794380-323 ® Shear Valve(s). ® Shear Valvas). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). •If the facility contains more tanks or dispensers. copy this forth. Include infirrmation 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, 1 have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): Guadalupe Sanchez Signatu, Certification No.: A30138 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: 10/21/2015 Page 1 of 4 Rev (2/08)