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MONITORING SYSTEM CERTIFICATION RECEIVED For Use By All Jurisdictions Within the State of California 77 ''((�� Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Cod eX Z1i2a17 This form must be used to document testing and servicing of monitoring equipment. A separate certification or.r 9t awf ftLokli, I I monitoring system control panel by the technician who performs the work. A copy of this form must be provid d`to the t syysste q� rator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date't':� Q �T:�9 A. General Information Facility Name: ARCO am/pm 83333 Bldg.No.: Site Address: 550 W.Valpico Ave. City: Tracy, CA Zip: 95376 Facility Contact Person: Edgar Contact Phone No.: (209) 836-3327 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 10/25/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ecled/serviced: Tank ID: T1: 87 Tank ID: T2: 91 Z In-Tank Gauging Probe. Model: 846390-109 ®In-Tank Gauging Probe- Model: 846390-109 ®Annular Space or Vault Sensor. Model: 794380-303 ®Annular Space or Vault Sensor. Model: 794380-303(split tank) ®Piping Sump/Trench Sensor(s). Model: 794380-208!794380-304 ®Piping Sump/Trench Sensor(s). Model: 794380-208!794380-304 ®Fill Sump Sensor(s). Model: 794380-2081794380-304 ®Fill Sump Sensor(s). Model: 794380-208!794380-304 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: 8484 Z Electronic Line Leak Detector. Model: 8484 ❑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: Diesel Y Tank ID: Z In-Tank Gauging Probe. Model: 846390-109 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794380-303(split tank) ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-208 1794380-304 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s)- Model: 794380-2081794380-304 E]Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model. 8484 ❑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 Z Dispenser Containment Sensor(s). Model: 794380-2081794380-304 Z Dispenser Containment Sensor(s). Model: 794380-208 1794380-304 Z Shear Valve(s). Z 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 Z Dispenser Containment Sensor(s). Model: 794380-208/794380-304 Z Dispenser Containment Sensor(s). Model: 794380-208/794380-304 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9&10 ; 11&12 Dispenser ID: 13&14 ; 15&16 Z Dispenser Containment Sensor(s). Model: 794380-208/794380-304 Z Dispenser Containment Sensor(s). Model: 794380-208/794380-304 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 Signatu Certification No.: A30138 License.No.: 1005444 Testing Company Name: Diamond Petroleum Services, Inc. Phone No.:(925) 470-0803 Testing Company Address: 3619 King Ct.Antioch,CA.94509 Date of Testing/Seryicing: 10/25/2017 Page 1 of 4 Rev(2/08)