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MONARING SYSTEM CERTIF9ATION For Use By All Jurisdictions Within the Mate 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 se arae certification or r ort must be re ared 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 PtCtNED"lating UST systems within 34 days of test date. A. General Information Facility Name: Fast N Easy MAR 0 12011 Bldg. No.: Site Address: 10879 N. Hwy 99 City: Stockton, Ca. Zip: 95212 Facility Contact Person: Bilal ENVIRONMENTAL HEALTH Contact Phone No.: 209 931-6154 Make/Model of Monitoring System: Veederr- oo N09 Date of Testing/Servicing: 1f2412011 B. Inventory of Equipment Tested/Certified Check tate ageroRriate boxes to indicate specific a ui meat ins eted/serviced: Tank ID: TI: 91 Tank ID:7Gauging ❑ In -Tank Gauging Probe. Model: ❑ in-Tankrobe. Model: Annular Space or Vault Sensor. Model: 794390-420 (split -tank)_^ ® Annular Space or Vault Sensor. Model: 794390-420 (split -tank) ® Piping Sump / Trench Sensor(s). Model: 794380-208 E Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: FX1 V ® Mechanical Line Leak Detector. Model: VMI LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El 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: 87 Tank ID: T4: Diesel ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390420 ❑ Annular Space or Vault Sensor. Model: 794390-420 (split -tank ❑ Piping Sump f Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FX1V ® Mechanical Line Leak Detector. Model: FX1V Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill I High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: [I� 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: X4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: 68x6 Dispenser ID: 7&8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ® Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Fioat(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, l have also attached a copy of the report; (check all that apply): System set-up ® Alarm history report Technician Name (print): Guadalu a Sanchez Signature- Certification No.: A30138 License. No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc, Phone No.: 209 945-8566 � ) — Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca. 95361 Date of Testing/Servicing: 112412011 Page i of 4 Rev (2/08)