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MONI*RING SYSTEM CERTIFATION 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 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 tanks stem owner/o erator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of tfqEE I /ED A. General Information �/ Facility Name: ARP MINI MART Site Address: 25775 Patterson Pass Road Facility Contact Person: Neilsh Patel Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Check the aaorooriate boxes to indientr snPritir ...:. Bhu y o.6 2011 No.. City: Tracy �• Contact Phone No.:L2M&AEB=Er+ Date of Testing/Servicing: 3/29/2010 : T-1 87 Slave Tank ID: T-2 87 Master nk Gauging Probe. Model: 107 ® In -Tank Gauging Probe. Model: 107 lar Space or Vault Sensor. Model: 407® Annular Space or Vault Sensor. Model: 407 Sump / Trench Sensor(s). Model: 208® FMechanical Piping Sump /Trench Sensor(s). Model: 208 ump Sensor(s). Model: 208® Fill Sump Sensor(s). Model: 208 anical Line Leak Detector. Model:❑ Mechanical Line Leak Detector. Model: onic Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: 8484 Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: T-3 87 Syphon Tank ID: T-4 Premium ® In -Tank Gauging Probe. Model: 107 ® In -Tank Gauging Probe. Model: 107 ® Annular Space or Vault Sensor. 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: 208 ® Fill Sump Sensor(s). Model: 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 E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 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: 208 ® Dispenser Containment Sensor(s). Model: 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 tank.- or dicni-mPre .,,,., a,:F _ r....i...,_ — - - -•- ••. -F., _01.,1111. 1111.1uu0 luuurmauon for every tanx 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 Signature: Certification No.: A30138 License, No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Testing Company Address: 11930 Horseshoe Road, Oakdale CA 95361 Page 1 of 3 Phone No.: (209) 845-8586 Date of Testing/Servicing: 4/7/2011 Rev (2/08)