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MONITIONG 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 This form 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 port 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 ownerloperator. 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 Facility Name: ARCO#09600,CC 18022603 City: STOCKTON CA Zip:95205 Site Address: 1250 N.WILSON WAY Contact Phone No: 465-5359 Date of Testing/Service: 04/16/2007 Facility Contact Person: MANAGER Make/Model of Monitoring System:V.R.TLS-350 Work Order Number: 2248616 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1-87 Tank ID: 2-89 X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 420 X Annular Space or Vault Sensor. Model: 420 )( Piping Sumpfrrench Sensors). Model. 323 X Piping Sump/Trench Sensogs). Model: 323 X Fill Sump Sensoria). Model: 323 Fill Sump Sensogst Model: 323 X Mechanical Line Leak Detector. Model: VAPOR LESS(LD-2000) X Mechanical Line Leak Detector. Model: VAPOR LESS(LD-2000) Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model. Tank Overfill/High-Level Sensor. Motlel'. Tank OverfilVHigh-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). TanklD: 6-U I Tank ID: In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model. 420 Annular Space or Vault Sensor, Model: X Piping Sumpftrench Sensoria). Model: 323 Piping Sumpfrrench Sensor(s). Model: X Fill Sump Sensor(s). Model: 323 Fill Sump Sensor(s). Motlel'. X Mechanical Line Leak Detector. Model: VAPOR LESS(LD-2000) Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank OveKIVHigh-Level Sensor. Model: Other(specify equipment type and model in Section Eon page 2). Other(specify equipment type and model in Section E on page 2). Ispenser : 1/4 DispenserlD: 5/8 X❑Dispenser Containment Sensors) Model:323 _Xj Dispenser Containment Sensors) Motlel'.323 X�Shear Valve(s). X Shear Valves) 0 Dispenser Containment Post s)and Chairi Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/12 Dispenser 10: 13/16 Dispenser Containment Sensor(s) Model:323 -Xi Dispenser Containment Sensor(s). Model:323 MShear Valve(s). Shear Valve(s). Dispenser Containment Floats)and Chain(s). 7 Dispenser Containment Floats)and Chaints). DispenserlD: 17/18 Dispenser ID: 19/20 X❑ Dispenser Containment Sensors) Model:323 X Dispenser Containment Sensor(s). Model:323 7 Shear Valve(s). X Shear Valve(s). Dispenser Containment Floats)and Chairi 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 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): ❑System set-upXI Alarm history report Technician Name(print): JOEY MESA Signature: Certification No.: 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: 04/16/2007 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification