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S MONIARING SYSTEM CERTIFI-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 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 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: Arco BP 2186 Bldg.No.: Site Address: 3212 N. California City: Stockton Zip: 95204 Facility Contact Person: Not reported Contact Phone No.: (209) 941-2694 Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 2122/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank 1D: 87 plain Tank ID: 87 aux ®In-Tank Gauging Probe. Model: mag probe ®In-Tank Gauging Probe. Model: mag probe plus ®Annular Space or Vault Sensor. Model: 409 ®Annular Space or Vault Sensor. Model: 409 ®Piping Sump/Trench Sensor(s). Model: 323 Z Piping Sump/Trench Sensor(s). Model: 323 ®Fill Sump Sensor(s). Model: 323 Z Fill Sump Sensor(s). Model: 323 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: cpt ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: probe Z Tank Overfill/High-Level Sensor. Model: probe ❑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: 91 Tank ID: Z In-Tank Gauging Probe. Model: mag probe ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 409 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 323 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 323 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: cpt ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: probe ❑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: 323 Z Dispenser Containment Sensor(s). Model: 323 Z Shear Valve(s).opw Z Shear Valve(s).opw ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 Z Dispenser Containment Sensor(s). Model: 323 Z Dispenser Containment Sensor(s). Model: 323 Z Shear Valve(s).opw Z Shear Valve(s).opw ❑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): Z System set-up ® Alarm history report Technician Name(print): Omar Ruiz Signature: C24a�::) Certification No.: B35686 License.No.: 794519-A HAZ C21 Testing Company Name: Fueling &Service Tech., Inc. (FASTECH) Phone No.:(714) 523-0194 Site Address: 7050 Village Drive, Suite D, Buena Park, CA 90621 Date of Testing/Servicing: 2/22/2011 Page I of 4