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MONITORING SYSTEM CERTIFICATION ece� For Use By All Jurisdictions Within the Stale of California "G`AEK°°"°"""` 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 indicate specific ec ui meat inspected/serviced: Tank ID: Tank TD: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑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 tvpe and model in Section E on Page 2). Tank ID: Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: I ❑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(specift equipment type and model in Section E on Page 2). Dispenser ID: 13-14 Dispenser ID: 15-16 Z Dispenser Containment Sensor(s). Model 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser Ill: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑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.cope 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 verih, 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): Nikola Zagorov Signature: tlGZO�V-ov 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 Paoe 2 of 6