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MONIT ING SYSTEM CERTIFI ION 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 certification or report mu c monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system o IVED The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. APR A. General Information 9 2012 EAIrIR�N Facility Name: WEST VALLEY CHEVRON AUTO SPA Bldg.��q MEN Site Address: 2615 W. Grantline Road City: Tracy Zip: 9 R�yic�_o Facility Contact Person: Linda Mutnik Contact Phone No.: (209) 836-3464 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 3/5/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: T1: Premium Tank ID: T2: Diesel ®In-Tank Gauging Probe. Model: 109 ®In-Tank Gauging Probe. Model: 107 ®Annular Space or Vault Sensor. Model: 303 ®Annular Space or Vault Sensor. Model: 303 ®Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 Z Dill Sump Sensor(s). Model: 208 ®Fill Sump Sensor(s). Model: 208 ❑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 Paye 2). Tank ID: T3: Unleaded Tank ID: Z In-Tank Gauging Probe. Model: 107 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 303 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 208 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: E 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: 208 Z Dispenser Containment Sensor(s). Model: 208 E 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 E Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 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: 208 Z Dispenser Containment Sensor(s). Model: 208 M 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 Signature: Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Road, Oakdale CA 95361 Date of Testing/Servicing: 3/5/2012 Page 1 of 3 Rev(2/08)