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MONI Y -)RING SYSTEM CERTIFk,ATION 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. A separate certification or report eared for each monitoring Ustem control panel by the technician who performs the work. A copy of this form must be provided to the The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. 4!1%� A. General Information r r,` 2 6 2012 Facility Name: ARP Mini Mart 76 1W1hbAo.: Site Address: 25775 So. Patterson Rd. City: Tracy, Ca. PSI %6L Hpa Facility Contact Person: Neil Patel Contact Phone No.: (5 0) 299-1219 ICf-S Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 3/21/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T1: 87 Slave Tank ID: T2: 87 Master M In -Tank Gauging Probe. Model: 847390-107 ® In -Tank Gauging Probe. Model: 847390-107 ® Annular Space or Vault Sensor. Model: 794390-407 ® Annular Space or Vault Sensor. Model: 794390-407 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: 8484 ❑ 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 G on Page 2). Tank ID: T3: 87 Syphon Tank ID: T4: 91 ® In -Tank Gauging Probe. Model: 847390-107 ® In -Tank Gauging Probe. Model: 846390-107 ® Annular Space or Vault Sensor. Model: 794390-407 ® Annular Space or Vault Sensor. Model: 794390.407 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leek Detector. Model: ® Electronic Line Leak Detector. Model: 8484 ❑ 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: 182 Dispenser ID: 384 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 ® 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: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ 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 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 Signaj!Er�_,=;;;zZ= J/ 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: 3/21/2012 Page 1 of 4 Rev (2/08)