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MONIZRING SYSTEM CERTIFt ATION RECEIVED 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 i 90161014 This form must be used to document testing and servicing of monitoring equipment. A separate certification or re ort 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 EAT>AWW". The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test datePERMIT/SERVICES A. General Information Facility Name: United Gas Bldg.No.: Site Address: 3440 E. Main St. City: Stockton, Ca. Zip: 95205 Facility Contact Person: Jean/Jino Lee Contact Phone No.: (209) 463-7716 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 6/30/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: T1: 91 Tank ID: T2: 89 ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390-420 ®Annular Space or Vault Sensor. Model: 794390-420 ®Piping Sump/Trench Sensor(s). Model: PA02592000000 ®Piping Sump/Trench Sensor(s). Model: PA02592000000 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: RJ XL(116-035) ®Mechanical Line Leak Detector. Model: VMI 99LD-2000 ❑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). Tank ID: T3: 87 Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390-420 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: PA02592000000 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: _ ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: FX1 V ❑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 ID: 1&2 Dispenser ID: 3&4 ❑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: 5&6 Dispenser ID: 7&8 ❑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 1D: Dispenser ID: ❑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). *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 Signature: c®� Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of Testing/Servicing: 6/30/2014 Page 1 of 4 Rev(2/08)