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MONITORING SYSTEM CERTIFICATION APR U 8 2018 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 EN] 1M�R NTAL This form must be used to document testing and servicing of monitoring equipment. A separate certification or report �ft.b_ir`�i`a7e�tTCt�t"T 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: ARP Mini Mart Mobil Site Address: 25775 S. Patterson Pass Rd. Facility Contact Person: Neil Patel Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment insnected/serviced: Bldg. No.: City: Tracy, CA Zip: 95376 Contact Phone No.: (510) 299-1219 Date of Testing/Servicing: 3/8/2018 Tank ID: T1: 87 Slave Tank ID: T2: 87 Master Z In -Tank Gauging Probe. Model: 847390-107 ® In -Tank Gauging Probe. Model: 847390-107 Z Annular Space or Vault Sensor. Model: 794390-407 Z Annular Space or Vault Sensor. Model: 794390-407 Z Piping Sump / Trench Sensor(s). Model: 794380-208 Z Piping Sump / Trench Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z 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). Tank ID: T3: 87 Syphon Tank ID: T4: 91 Z In -Tank Gauging Probe. Model: 847390-107 Z In -Tank Gauging Probe. Model: 846390-107 Z Annular Space or Vault Sensor. Model: 794390-407 Z Annular Space or Vault Sensor. Model: 794390-407 Z Piping Sump / Trench Sensor(s). Model: 794380-208 Z Piping Sump / Trench Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z 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 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5&6 Dispenser ID: 78,8 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s), Model: 794380-208 Z Shear Valve(s). Z 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 Certification No.: A30138 License. No.: 1005444 Testing Company Name: Diamond Petroleum Services, Inc. Phone No.: (925) 470-0803 Testing Company Address: 3619 King Ct. Antioch, CA. 94509 Date of Testing/Servicing: 3/8/2018 Page 1 of 4 Rev (2/08)