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' MONIT(ONG SYSTEM CERTIFICAOON 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 Thisfgr;n must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility,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 CA Zip:95240 Facility Name: ARCO 2076,CC 18022641 City: LODI Site Address: 800 KETTLEMAN LN Contact Phone No: 334-3678 PTO N-85 Date of Testing/Service: 07/11/2006 Facility Contact Person: MANGER Make/Model of Monitoring System:V.R.TLS-350 Work Order Number: 2243776 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced R -91 Tank ID: 2-87MASTER Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG Space or Vault Sensor. Model: 407 X Annular Space or Vault Sensor. Model: 407 umprrrench Sensor(s). Model: 323 X Piping Sumpfrrench Sensor(s). Model: 323 p Sensor(s). Model: 323 Fill Sump Sensor(s). Model: 323 ical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ic Line Leak Detector. Model: PLLD X Electronic Line Leak Detector. Model: PLLD 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: Tank ID: X In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 407 Annular Space or Vault Sensor. Model: 407 X Piping Sump/Trench Sensor(s). Model: 323 X1 Piping Sumpfrrench Sensor(s). Model: 323 X Fill Sump Sensor(s). Model: 323 L11q Fill Sump Sensor(s). Model: 323 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑ 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 : 1/2 Dispenser ID: 3/4 X❑Dispenser Containment Sensor(s) Model:323 X Dispenser Containment Sensor(s) Model:323 Shear Valve(s). X Shear Valve(s) ElDispenser Containment Float(s)and Chain(s). 1Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 RI Dispenser Containment Sensor(s) Model:323 Dispenser Containment Sensor(s). Model:323 X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: nDispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). ElDispenser 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 manufacturersguidelines. Attached to this certification is information(e.g manufacturers'checklists)necessary to verify that this information is correct. and a Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): El System set-up Alarm history report Technician Name(print): JOEY MESA Signature: : Certification No.: 006-05-1532 License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 07/11/2006 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification