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MONITOR SYSTEM CERTIFICAT � �� ll ��cD 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, Californitisin f Regulations ^�jj; This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control paailed at the facility,a separate �"vb certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy m must be psystem owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 st date. rr'VI`d 1Y 1 HALT PERK?!T/SERVICFS H A.General Information Facility Name: ARCO#06020,CC 18022765 City: MANTECA CA Zip:95336 Site Address: 1711 E YOSEMITE Contact Phone No: 823-4715 Date of Testing/Service: 08/22/2006 Facility Contact Person: MANAGER Make/Model of Monitoring System:TLS-350 Work Order Number: 2244474 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1-UL Tank ID: 2-MID 71 In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model. MAG 5fl Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: 409 X Piping Sumpfrrench Sensor(s). Model: 323 X Piping Sumprrrench Sensor(s). Model: 323 RxFill Sump Sensor(s). Model: 323 Fill Sump Sensor(s). Model: 323 Mechanical Line Leak Detector. Model: MLD X Mechanical Line Leak Detector. Model: XLD Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Modal: Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model ih Section E on page 2). Tank ID: Tank ID: 71 In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Mod I: X Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Mod I: X Piping Sumprrrench Sensor(s). Model: 323 Piping Sump/Trench Sensor(s). Mod I: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Mod I: X Mechanical Line Leak Detector. Model: XLD Mechanical Line Leak Detector. Mod I: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Mod I: 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 : 1/2 3/4 Dispenser ID: 5/6 7/8 Dispenser Containment Sensor(s) Model:323 X Dispenser Containment Sensor(s) Model:323 X❑Shear Valve(s). X Shear Valve(s) ❑Dispenser Containment Float(s)and Chain(s). 7 Dispenser Containment Float(s)and Chai (s). Dispenser ID: 9/10 Dispenser ID: 11/12 x❑Dispenser Containment Sensor(s) Model:323 . Dispenser Containment Sensor(s). Mod I:323 X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 13/14 Dispenser ID: 15/16 Dispenser Containment Sensor(s) Model:323 il Dispenser Containment Sensor(s). Mod I:323 ❑X Shear Valve(s). 7X Shear Valve(s). 10 Dispenser Containment Float(s)and Chain(s). 0 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 Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports.I have also attached a copy of the(Check all that apply): ❑System set-up X❑Alarm history report Technician Name(print): DOUGLAS HARTY Signature: r Certification No.: 006-05-0253 License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 08/22/2006 Monitoring System CertificationPage 1 of 3 Based on CA form dated 03/01