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DPCIMIED MONITORING SYSTEM CERTIFICATION NOV 1 S 2016 For Use By A11 Jurisdictions Within the State ofCaWornia Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 13, Call GOfle�Regu/ations _ - ) I-�q1 n T This form must be used to document testing and servicing of monitoringequipment. A e ante certification or �f r*J� I H pal'be 0reoared for each monitoring sustain control panel by the technician who the the work. A copy of this forth must be prondad to the tank The owner/operator Inmos[submit a copy of this form to the local agency regulating UST systems within 30 days of test date, system owner/operator. A. General Information Facility Name: Arco Site Address: 1340 Colony Rd Bldg.No.: City: Ripon,Ca. Zip: 95366 Facility Contact Person: Ranjeet Contact Phone No.: (2 9) 579-4014 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 10/20/2016 B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicates cine at meat Ins ected/serviced: Tank ID: T1: 87 Tank ID: T2:91 ®In-Tank Gauging Probe. Model: 848390-111 N In-Tank Gau n Probe. ®Annular Space or Vault Sensor. Model: 794380-303 Gauging Model: 8 4 6 3 9 0.111 ®Annular Space or Vault Sensor. Model: 794380-303(split tank) N Piping Sump/Trench Sensor(s). Model: 794380-208/794380-304 Z Piping Sump/Trench Sensor(s). Model: 794380-208/794380.304 N Fill Sump Sensor(s). Model: 794380.208/794380-304 Z Fill Sump Sensor(s). Model: 794380-208 1794380-304 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: 8484 Z Electronic Line leak Detector. Model: 8484 ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-level Sensor_ Model: ❑Other(specify equipment type end model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). p Tank ID: T3: Diesel Tank ID: N In-Tank Gauging Probe. Model: 846390-111 El In-Tank Gauging Probe. Model N Annular Space or Vauh Sensor. Model: 794380.303(split tank) ❑Annular Space or Vault Sensor, Model: N Piping Sump/Trench Sensor(s). Model: 794380-208 1794380-304 ❑Piping Sump Sensor(s). SensoKs). Model: Z Fill Sump Srnsor(s). Model: 794380-2081794380304 [1 Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line teak Detector. Model: 8484 ❑Electronic Line Leak Detector. Model: ❑Tank Orli/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Others eci equipment (P fY type and model in Section E on Page 2), Dispenser ID: 1&2 Dispenser ID: 3&4 N Shear Valve(s). Z Dispenser Containment Sensogs). Model: 794380-2081794380-304 Z Dispenser Containment Sensor(s). Model: 794380.208/7943 80-304 Z Shear Valve(s). El Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 N Dispenser Containment Sensor(s). Model: 794380.2081794380-304 Z Dispenser Containment Sensor(s). Model: 794380.208/794380.304 Z Shear Valve(s).❑ N Shea Valvc(s), Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Cham(s). Dispenser ID: 9&10 ;11&12 Dispenser ID: 13&14; 15&16 N Dispenser Containment Seasons). Model: 794380-208/794380.304 Z Dispenser Containment Sensor(s). Model: 784380.208/794380-304 Z Shear Valve(s). Z Shcar Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). .IT the facility contains more tanks or dispensers,copy this forth. 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,1 have also attached a copy of the report;(check all that apply); ®System set-up ®Alarm history report Technician Name(print): Guadalupe Sanchez Signatt=/' 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: 10/20/2016 Page 1 of 4 Rev(2/08)