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HE i7 MONI )RING SYSTEM CERTIF. ATI Ll For Use By All Jurisdictions Within the State ON WED Authority Cited. Chapter 6.7, Health and Safety Code,Chapter 16, Division 3 Titlf 23,i California Code of R�la,'io?u ZrJ] This form must be used to document testing and servicing of monitoring equipment. A se crate certification or re ort t o � O E� r Tj ? f monitories sysrat control panel by the technician who performs the work. A copy of this form must be provided to the tan H The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. plV9 v A. General Information Facility Name: MAIN STREET ARCO#82617 Site Address: 1100 S. Main Street Bldg.No.: Facility Contact Person: Jasbir Chadds City: Manteca Zip: 95337 Make/Model of Monitoring System: Veeder Root TLS-350 Contact Phone No.: (209) 825-6784 Date of Testing/Servicing: 3/25/2010 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific a ui ment inspect d/serviced: Tank ID: T1: 87 Tank ID: 72. 91 Z In-Tank Gauging Probe. Model: 847390-109 ®In-Tank Gauging Probe. Model: 847390-109 ®Annular Space or Vault Sensor. Model: 794390.409 Z Annular Space or Vault Sensor. Model: 794390-409 ®Piping Sump/Trench Sensor(s). Model: 794380-323 Z 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: LD2000 ®Mechanical Line Leak Detector. Model: STP-MLD ❑Electronic Line Leak Detector. Model: C3 Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: I ❑Tank Overfill/High-Level Sensor. Model: ❑Other(Specify equipment type and model in Section E un Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: T3: 89 Tank ID: ®In-Tank Gauging Probe. Model: 847390-109 ❑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: Z Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: STP-MLD ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: �I ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(s7zt ecifi equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Paee 2).. 1 &6 ,; Dispenser ID: 2 & 5 nainment Sensor(s). Model: 794380-323 ®Dispenser Containment Sensor(s). Model: 794380-323 ). ®Shear Valve(s). ntainment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s), Dispenser ID: $$4 Dispenser ID: 7 8� 12 ®Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). ®shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 8& 11 Dispenser ID: 9 & 10 Z Dispenser Containment Sensor(s). Model 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). Z 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 Signature: Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Service Inc. Phone No.:(209) 845-8586 Testing Company Address: 521 Branding Iron Street,Oakdale CA 95361 Date of Testing/Servicing: 3/25/2010 Page 1 of 4 UN-036—1/5 www.unidoes.org Rev.01/17/08