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MONITORING SYSTEM CERTIFICATION Ei c e/) For Use By All Jurisdictions Within the State of California " "-�COW—CE 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 Bldg.No.: Site Address: 550 W.Valpico Road City: Tracy,CA Zip: 95376 Facility Contact Person: Edgar Rizkalli Contact Phone No.: (925) 548-7910 Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 10/30/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: #1 87 20 000 Gal Tank ID: #2 91 12 000 Gal Z In-Tank Gauging Probe. Model: MAG-1 Z In-Tank Gauging Probe. Model: MAG-1 Z Annular Space or Vault Sensor. Model: 794380-301 Z Annular Space or Vault Sensor. Model: 794380-301 Z Piping Sump/Trench Sensor(s). Model: 794380-208 Z Piping Sump/Trench Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: VR Series 8484 Z Electronic Line Leak Detector. Model: VR Series 8484 Z Tank Overfill/High-Level Sensor. Model: VR Overfill Alarm Z Tank Overfill/High-Level Sensor. Model: VR Overfill Alarm ®Other(specify equipment type and model in Section E on Page 2) Z Other(specify equipment type and model in Section E on Page 2). Tank ID: #3 Diesel 8 000 Gal Tank ID: Z In-Tank Gauging Probe. Model: MAG-1 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794380-301 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: VR Series 8484 ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: VR Overfill Alarm ❑Tank Overfill/High-Level Sensor. Model: Z Other(specifi equipment type and model in Section E on Page 2). ❑Other(speciR,equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 34 Z Dispenser Containment Sensor(s). Model. 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser Ill: 5-6 Dispenser ID: 7-8 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 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 Dispenser ID: 11-12 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 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/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 equipment capable of generating such reports,I have also attached a copy of the report; (check all that apptr): ® System set-up ® Alarm history report Technician Name(print): Nikola Zagorov Signature: N �rC)V Certification No.: Veeder Root Level 4#A32784 License.No.: 958763 A Testing Company Name: ECO-CHEK Compliance, Inc. Phone No.:(888) 500-CHEK Testing Company Address: P.O. Box 77194, San Francisco CA 94107 Date of Testing/Servicing: 10/30/2014 Pale 1 of 6 Rev(2/08)