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MONIARING SYSTEM CERTIF .,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 se arate certificatio or each monitoring system control panel by the technician who performs the work. A copy of this form must be provi t / erator. 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 APR 12 2011 Facility Name: Arco ENVIR0I f&:Ha4hT4_ Site Address: 1100 S. Main St. City: Manteca PERMIT/2WAM37 Facility Contact Person: Jessie Contact Phone No.: (209) 609-0117 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 3/31/2011 B. Inventory of Equipment Tested/Certified Check the apgropriate boxes to indicate specific equipment inspected/serviced. Tank ID: T1: 87 Tank m: T2. 91 E In-Tank Gauging Probe. Model: 847390-109 E In-Tank Gauging Probe. Model: 847390-109 ®Annular Space or Vault Sensor. Model: 794390-409 E Annular Space or Vault Sensor. Model: 794390409 ®Piping Sump/Trench Sensor(s). Model: 794380-323 E Piping Sump/Trench Sensor(s). Model: 794380-323 E Fill Sump Sensor(s). Model: 794380-323 E Fill Sump Sensor(s). Model: 794380-323 E Mechanical Line Leak Detector. Model: 99LD-2000 E Mechanical Line Leak Detector. Model: FE 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: T3' 89 Tank ID: E In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: 794390.409 ❑Annular Space or Vault Sensor. Model: E Piping Sump/Trench Sensor(s). Model: 794380-323 ❑Piping Sump/Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: FE STP-MLD ❑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: 1&2 Dispenser ID: 3&4 E Dispenser Containment Sensor(s). Model: 794380-323 E Dispenser Containment Sensor(s). Model: 794380-323 ®Shear Valve(s). E 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 E Dispenser Containment Sensor(s). Model: 794380-323 E Dispenser Containment Sensor(s). Model: 794380-323 E Shear Valve(s). E Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9&10 Dispenser ID: 11&12 E Dispenser Containment Sensor(s). Model: 794380323 E Dispenser Containment Sensor(s). Model: 794380-323 E Shear Valve(s). E 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 equi meat. For any equent capable of generating such reports,I have also attached a copy of the report;(check all that apply): IN i w System set-up Alarm histo report Technician Name(print): Guadalupe Sanchez _ Signa Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of Testing/Servicing: 3/31/2011 Page 1 of 4 Rev(2/08)