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MONITOANG SYSTEM CERTIFICATION Fo By All Jurisdictions Within the State of California M Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3 7-dle 23,Caldb, 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 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 Facility Name: ARCO/B.P.#9600,CC 18022603 City: STOCKTON CA Zip:95205 Site Address: 1250 N.WILSON WAY Contact Phone No: 465-5359 Date of Testing/Service: 04/19/2006 Facility Contact Person: MANAGER Make/Model of Monitoring System:V.R.TLS-350 Work Order Number: 2242205 B.Inventory of Equipment Tested/Certifled Check the appropriate boxes to indicate specific equipment inspected/semiced TanklD: 1-87 TanklD: 2-89 71 In Tank Gauging Probe, Model: MAG In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: 420 71 Piping Sump/Trench Sensor(s). Model: 323 Piping Sump/rrenoh Sensor(s). Model: 323 X Fill Sump Sensor(s). Model: 323 FH Sump Sensor(s). Model: 323 Mechanical Line Leak Detector. Model: LD-2000 X Mechanical Line Leak Detector. Model: LD-2000 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OvemllAiiglFLevel Sensor. Model: 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). Tank TanklD: X1 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 Sump/french Sensor(s). Model: 323 Piping Sumprrrenrh Sensor(s). Madel: X Fill Sump Sensor(s). Model: 323 Fill Sump Semor(s). Madel: X Mechanical Line Leak Detector. Model: LD-2000 Mechanical Line Leak Detector. Madel: Bectronk Line Leak Detector. Model: Electronic One Leak Detector. Model: Tank OvemlVHigh-Level Sensor. Model: Tank OvenfillMigh-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 Sensors) Model:323 X Dispenser Containment Sensors) Model:323 X Shear Valve(s). X1 Shear Valve(s) EjDispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/8 Dispenser ID: 9/11 FlDispenser Containment Sensor(s) Model:323 71 Dispenser Containment Sensor(s). Model:323 X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)aro Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 12/15 Dispenser ID: 16/20 Dispenser Containment Sensogs) Model:323 X Dispenser Containment Sensor(s). Model:323 X Shear Valve(s). X Shear Velvets). Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chants). 'If the facility contains more tanks or dispensers,copy this forth.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-up Alarm history report Technician Name(print): JOEY MESA Signature: / I'V 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: 04/19/2006 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification