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MONITORING SYSTEM CERTIFICAT7cREC E I VE® Authority Cited;Chapter G.iFor Ure By.411 Jurisdictions within the State of California , Health and Safety Code; Chapter 16,Division 3, 7}Jle 2.i, California Cc,,&of Regutadnrrs This form most he used to document;.sting and sc,ti icing of munitoring equipment.A scoorete certification or r pert mr�j ° 4E eaet tr tmitnrin stem control ;net by Iho technician who performs the work. A copy of this fom,mutt he provided to the tank sysa n owner/p The owncrroperator mus'.submit s copy of this form to the]Deet Aerator. agency reguiadrig(IST sy9tcmy Aith(n 10 d"s�N (...NMEOTAL HEALTH A. General Information DEPARTMENT Futility Name: United Gas Bldg.No.; Site Address: 3440 E, Main St. Ciry: Stockton,Ca. zip. 95205 1'aeiiity Contact Person: Jean 1 Jino l.ee Contact Phone No.: (209) 463-7716 Make/Modei Of Monitoring System: Gilbarco EMC Date ofTestittg/Servicing: 613012014 B. Inventory of Equipment Tested/Certified Chick ttte npproprisic buics to indicate spel,i t ui meat i,lf cctcoiserviced: Tank ID: TI:91 Tank ID: T2. 89 ❑In-Tank Gauging Nmhe Mode: ❑In-Tank(Gauging Probc. Model: ®Annular Space or Vault Sensor Model: 794390420 0 Annular Splice or Vault Sensor. Model. 790390.420 ®Piping Sump/Ttinch Sersor(s). Model. PA02692000000 Z Piping Sump/Trench Sensor(:). Modci: PA02592000000 ❑fill Sump Sensur(c). Mc,dcl ❑Fill Sump Scnsor(s). Model: ®Mcchanicnt Line Leak Dct..etor. Moet: RJ XL(116-035) (Scj kiechcut c l Linc Leak Octcctor Model- VMI 9XD-2000 ❑Electronic Linc I cuk Datilim r. Mucci. ❑FICCTWre Linc l talc:Detector_ tvfodtt: ❑TAttkOver fill/High-level Scnsur. Model: [7 Tank Ov tl/High-t eves Sensor. Model: )✓Uthc (specify equipment type and:trodcl in Scctian E to Page 2). ❑Other(specify equipment type ant model in Section Fun Pagc 2). Tanta Il(1: T3: 87 Tank ID: ❑M-Tank Ganging Frobe. Model: ❑LrTank Gauging Probe Model Annutor Spiky or Vault Sensor. Model: 794390-420 ❑Annular Space or Vault Sensor. hIodal; ®Pi?ing Sump/Trench Sensor,s). Modd: PA02692000000 ❑Piping Sump/Trcnch Sen-sor(s). M1,dcl: ❑Fl::Sump Sensor;,) Model: ❑fill Sump$ensttt(s). Model: ®Mechanical Lice Le-k Joromr. Model: FXIV ❑IMechsnical Line Leak Detector. Model: ❑GlLamnic nine Lcak Detector Modci ❑Yketronic Line Leak Detec6ac Modcl: ❑Tank Overfill/High-Level Semur. Mndel: ❑Tank OverfilO High-Level Sensor. Mntlel: ❑Othet(spdciry aqutpmcnt type and me, rl in Scctlon Lon Pao 2. fd ) Q Other(specify cquiprncnt type and model in Sectica V on Page 2) Dispenser ID- 1&2 Dispenser ID: 3&4 7)Dispen�cr(-ontainmcni Sensor(s). Model: [Dibpenser Containment ser.sor(s) Model_ 1K Shear Valve(:). ®Shear vatvc(s). CK Dispe7ser COntamntent Float(.;);tui(."hain(s). ®Dispenser Containntatt float(sl and Clttrot(s). Di:pcaser ID: 5&6 Dispenser ID: 78.8 ❑onpcnscr ContainimAl Sensor(s). Model: ❑Disptnsel Containment Sewor(s), Modd ®Chear vrilv;{s). :9 shear valvas). ®DisGmset Containment tlom(s)and Chain(:). ®Dispenser conminmcn;Flyat(s)and Chain(s). Disperser ID: Dispenser ID. G�ispcnser Contvna crit Sensori:) mode: ❑Shcur v� ❑DisperlscrConns tainmen[Stnr(s)• Model: ye(s). ❑shear valvt(t). ❑Disperser t:ontainrtttrtt Floats)Aid CLain(s). ❑Dispenser Containment rioaq,%)and Chain(s). *If the facility contains more teaks or dispensers,copy:his form Include info=86on for every tank anc dispenser at the facility C. Certification -l certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. A(Uched to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout or monitoring equipment ror any equipment capable of generafi„g such reports,I have also attached a copy ofthe report;(check all that apply): System set-up Alarm history report Technician Name(print): Guadalupe Sanchez _ Signature; Certification X10.: A30138 License.No.: 883706 Testing Cornriany Name: Reliable Petroleum Services Inc. Phone No.:L09) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of T csting/Servicing 6/30/2014 Page 1 of 4 Rev(2/08) 7-d £5689V960Z wneloaled elge1le2i eZ l:90 b 1 6£Inf