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May 10 11 01:15p Reliable Petroleu--'\ Authority Cited. • ( This form must be used to monitoring; system control E The ownerioperator must su A. General Informs Facility Name: ARP MI Site Address: 25775 P< Facility Contact Person: Make/Model of Monitorit B. Inventory of Eqt 2PQ-845-8953 p.2 MONITORING SYSTEM CERTIFI A TION For Use By All Jurisdictions Within the State of California Ater 6.7, Health and ,Safety Code, Chapter 16, Division 3, Title 23. California Code o.. ffReoulations MAY 1 0 Z01r :ument testing and servicing of monitoring equipment. A separate certification or report must be prepared for each I by the technician who performs the work. A copy of this form must be provid0jto.thc tank systettt-ownedoperator. t a copy of this form to the local agency regulating UST systems within 30 days oflest date. )n MART rson Pass Road eilsh Patel System: Veeder Root TLS -350 ioment Tested/Certified Bldg. No.: City: Tracy Zip: 9537$ Contact Phone No.: 209 830-7777 Date of TestinglServ•icing: 417/2011 �FTank ID: T-1 87 Slave Tank ID: T-2 87 Master In -Tank Gauging Probe. Model: 107 ® In -Tank Gauging Probe. Model: 107 ® Annular Space or Vault Set r. Model: 407 ® Annular Space or Vault Sensor. Model: 407 Piping Sump /Trench Senso (s), Model: 2080 Piping Sump/ Trench Sensor(s). Ntode.c 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Ser sor(s). Model: 208 ❑ Mechanical Line Leak DetecModel: or ❑ Mechanical Linc Leak Detector. Model: ❑ Electronic Line Leak Dctect Model: ® Electronic Line Leak Detector. Model: 8484 ❑ Tank Overfill! High -Level S nsor. Modei: ❑ Tank Overfill 1 High -Level Sensor. Model: ❑ Other (specify equipment ty and model in Section E on Page 21. Q Other (specify equipment type and model in Section E on Page 2). Tank ID: T-3 87 S h0 Tank ID: TSL Premium ® ]n -Tank Gauging Probe. Nlodel: 107 ® In -Tank Gauging Probe. Nlodel: 107 ® Annular Space or Vault Se r. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump/ Trench Sensor s). Model: 208 ® Piping Sump ! Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 20B ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detect sr. Model:❑ Mechanical Linc Leak Detector. Model: ❑ .Electronic Line Leak Deteeto Model: Leak rktector. ® Elec!ropContainment 8484 ❑ Tank Overfill)' High -Level S � sor. Model: ❑ Tank Oligh-Level Sensor. ❑ Other (specify equipment typ ;and model in Section E on Page 2). ❑ Other (uipment type andSection E on Paas 2). Dispenser ID: 112 Dispense14 gChainisl. ® Dispenser Containment Sens (s). Model: 208 DispeninmentSensor(s). Model: 208 ® Six tr Vttive(s). ® Shear ❑ Dispenser Containment Float(3) and Chain(s). ❑ Dispeninment Floats) an Dispenser ID: 516 Dispenser ID: 718 1211); spenser Containment Senso s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 21 Shear Valve(s).�j ') Shear Valve(s). C-1 Dispenser Containment Float( and Chain(s). ❑ Dispenser ConuJnmc:nt Float(,1 and Chaints). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Senso (s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Velvets). ❑ Shear Valve(s). ❑ Dispenser Containment Float(.) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *11' the farility rnntai— -- t n4.•—A:..... ----- I_. - -— __rj ---- ••,••••. •••_.— L.—,.114Q I wI cvciy 6anAanu uispcnscr at me melttty. C. Certification -I cer ify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached tc this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan howing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have also attached a copy of the re port; (check all that apply): M System set-up M Alarm history report Technician Name (print): Certification No.: A30131 Testing Company Mame: Testing Company Address: lune Sanchez fable Petroleum Services Inc. 11930 Horseshoe Signature:•-��-- License. No.: 883706 Oakdale CA 95361 Page 1 of 3 Phone No.: (209) 845-8586 _ Date of Testing/Servicing: 4/712011 Rev (2/08)