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MONITORING SYSTEM CERTIFICATION 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 AmPm #2186 Bldg.No.: Site Address: 3212 N. California St. City: Stockton,Ca Zip: Facility Contact Person: Kevin Vo Contact Phone No.: (209) 941-2694 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 5/22/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ectcd/serviced: Tank ID: T-1 87 Master Tank ID: T-2 87 Siphon ®In-Tank Gauging Probe. Model: 846390-109 ®In-Tank Gauging Probe, Model: 846390-109 ®Annular Space or Vault Sensor. Model: 794390.409 ®Annular Space or Vault Sensor. Model: 794390-409 ®Piping Sump/Trench Sensor(s). Model: 794380-323 ®Piping Sump/Trench Sensor(s). Model: 794380-323 ®Fill Sump Sensor(s). Model: 794380-323 ®Fill Sump Sensor(s). Model: 794380-323 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: CPT ®Electronic Line Leak Detector. Model: CPT ❑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: T-3 91 Tank ID: ® In-Tank Gauging Probe. Model: 846390-109 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390-409 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 794380-323 ❑ Piping Sump/Trench Sensor(s) Model: I� Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model. CPT ❑Electronic Line Leak Detector. Model: ❑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 M Dispenser Containment Sensor(s). Model: 794380-323 ®Dispenser Containment Sensor(s). Model: 794380-323 ®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: 794380-323 ®Dispenser Containment Sensor(s). Model: 794380-323 ®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 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/seryiced 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 equi ment 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): Pete Garcia Signature: Certification No.: A23970 License.No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.:(925) 551-4777 Testing Company Address: 6747 Sierra Ct., Dublin, Ca Date of Testing/Servicing: 5/22/2009 Page 1 of 3 Rev(2/08)