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Apr 28 14 03:55a Reliable Petrole lm 2098458953 p.2 04/28/2014 7:07AM =A% '9252 371 Guadalupe Sanchez 20002/0015 MONITORING SYSTEM CERTIFICATION For Use By Ail Jurisdictions Within the Stale of California Authurity Cited:Chapter 6.7.Health and Safety Code; Chapter 16, Division 3. Title 23,California Code of Regtrlatium 'Phis- form must be used to dMumenl testing tend ser�wing of monitoring equipment A scparu!e c-,wify;gion or report must be vroonred for each morutorme system oontrol panel by the technician who perParms the work. A copy of this form mu,[be provided to the conk systetn tmmcrioperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 drys of test date. A. Genera!Information Facility Name: ARP Mini Mart 76 Bldg.No.:_ Site Address: 25775 So.Patterson Rd. City: Tracy,Ca. Zip: 9537.6 Facility Contact Person: Nell Patel Contact Phone No_: (510) 299-1219 kfake/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Seivicing: 3/2812014 B. Inventory of Equipment Tested/Certified Check the Appropriate(nixes to indicatespecific.c u iniac ins ecttd/serviced: Tank T1: 87 Slave Tanis iw T2: 87 Master � { N=t orik Gauging Pmbe_ Model: 847390-107 ®in-Truk Gauging Probe. Model: 847390.107 Annular Space or Vault Sensor. 'lock:: 794390-407 Annular Space or Vauir .Sensor. Model: 794380-407 �l Piping Sump/french Sensor(y;. Vocel: 794380-208 ®Piping Sump/Treuch Senscr(s). Mudd 794380.208 Fill$ump Scnsnr(s). ;yodel: 794380-208 ®Fill Sump Sensor(S), Model: 794350.208 ❑ Mechanical Line Leak Detector. Model. ❑Mechanical Line Lcak Ociecior Mudel: ❑Eectronic Linc Lu*wocior Model: ®Ekctroaie Lino Leak Detector. Modcl: 8484 ❑Tank Overfill i kithclival Sensar. Model: ❑Tank Overfill/I ligh-Level Sensor. Model: ❑00W7(specify cquipment type and model in Section r-on Page 2). ❑Mbar(specify equipmew type and model in Smtiun G on Page 2). Tank Oa: T3:87 Syphon _ Tank ID: T4.91 2 Li-Tank Gauging Probe. Mudcl: 847390-107 ®in-'Tank Gauging Probe, Model: 846390.107 ®Annular Space ur Vault Sensor. Model: 784380-A07 ®Annular Space or Vault Sensor Model794390407 _ ®Piping Sump I Trench Sensor(s). Model: 794380-288 ®Pipu:g Sump/Trend, Model 794380-2N Fill Sump Sensor(s). Model: 794380.208 ®Fiji Sump Sensor ). Model: 794380-206 ❑Mechanical Linc Leak Detcator. Model: ❑Mechanical Line Leak Detector. Model: ❑6'1ec rtmlc Line Ltok Detector. Model ®Electronic Linc Leat:0tecu r Model: 8404 [}Tank Overfill/High-Leve)Sensor. Model: ❑Tank Overfill I Nigh-Level Sensor. MoccI- ❑Other(specifj equipment type and model in Scetion F.(in Page 2). ❑011ie.-(specilyequipment Lypc and model in Section E on Nage 2). Dispenser 111): 1$2 Dispenser ID: 3&4 ®Dispenser Cuntuinment Sensor(s). Model. 794380-20B d Dispenser Cantairtment Sensor(s). Model: 794380-208 ®Shear vnlve(s). m Shea:valvc(s). ❑DispcnsaContainmcnLFlont(s)oad Chain(s). ❑17ispcnserCoolatiuncttt Floats)and Chatn(s). Dispenser ID: S&6 Dispenser ID: 78.8 ®Dtsp=xr CDmaimnent Sensnr(s). Model: 794380-208 ®DiSlrenser Contaimncm Sensor(s). Model: 794380-208 ®Shear valve(s). ®Shear Valve(s). ❑-)ispenset CotttainrnCnt flow(a)and(�hain(ti). ❑Disperser(:unlIIinment Iloet(s)and Chain(s), Dispenser ID: Dispenser ID: C Dispenser Coutauncnt Sensor(s). Model: ❑Dispenser Containment Sensoi(s). Modcl ❑Shear va:vc(s). ❑Shear vatYe(s). ❑Dispcmer Containtnent Float(s)and Chain(s). ❑Disperscr Conwinmtnt Floats)and Chain(s). 'If the facility contains more tanks or dispenses,copy this form. Include information for every tank and dispenser at the fadUry C. CertlfiCation -f certify thaL the equipment identified in this document was Inspectedtserviced in accordance with The manufacturers' guldetines. 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 equt went -'a PA of generating such reports,I have also attached a copy of the report:(check aft r4at apply): ®system set-up Alarm history report Technician Nme(Print): Guadalupe Sanchez Signature c Certification No.: A30138 Licenst.No.: 883706 Testing Company Name: Reliable Petroleum Services,Inc- Phonc No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd.Oakdale,Ca.95361 Date of Tesling/Servicing: 3128/2014 Page 1 of 4y 1 a L ` 4 l7�ydj y � Kl Rev(2/08) APR 2 8 2014 ENVIRONMENTAL HEALTH DEPARTMENT