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FED fi�f MONIVMNG SYSTEM CERTIFISkTION /LLQ 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 pff*gul�iom 7 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 ste n'p"er/6 , , The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. 0'.1,!,)r, A. General Information Facility Name: ARCO Bldg.No.: Site Address: 1100 S Main City: Manteca Zip: 95337 Facility Contact Person: Contact Phone No.: (209) Make/Model of Monitoring System: TLS 35OR Date of Testing/Servicing: 3/15/2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: T-1 UNL Tank ID: T-2 PREM ®In-Tank Gauging Probe. Model: 847390-109 ®In-Tank Gauging Probe. Model: 847390-109 ®Annular Space or Vault Sensor. Model: 794390-407 ®Annular Space or Vault Sensor. Model: 794390-407 ®Piping Sump/Trench Sensor(s). Model: 794380-323 ®Piping Sump/Trench Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: LD-2000 ®Mechanical Line Leak Detector. Model: STP-MLD ❑Electronic Line Leak Detector. Model: ❑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). Tank ID: T-3 PLUS Tank ID: ®In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390-407 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 794380-323 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: LD-2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑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: 116 Dispenser ID: 2/5 ®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: 3/4 Dispenser ID: 7/12 ®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: 8/11 Dispenser ID: 9/10 ®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). *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 hisio,Iy�eport Technician Name(print): Gavin Williams Signature: / 1L Certification No.: 5285969-UT License.No.: 05857 Testing Company Name: HMC-Henderson Maint Co Phone No.:(209) 467-7573 Site Address: PO Box 31325, Stockton, CA 95213 Date of Testing/Servicing: 3/15/2007 Page 1 of 3