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MON Ir RING SYSTEM CERTIF TI0TRECENED For use By All Jurisdictions Within the State of Cali is Authority Cited: Chapter 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Co"R�lali6rii� 6. This form must be used to document testing and servicing of monitoring equipment. A separate certification orf 1RtQN fffiktF_p1 R6 monitoring system control panel by the technician who performs the work. A copy of this form must be provided to th � �f V tor. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test 1tMe. ' A. General Information Facility Name: ARCO AM PM Bldg.No.: Site Address: 1711 E.Yosemite Avenue City: Manteca Zip: 95336 Facility Contact Person: Paul Singh Contact Phone No.: (209) 8234715 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 5126/2010 B. Inventory of Equipment Tested/Certified Check the anorODriatc boxes to indicates eclfic equipment Inspected/serviced: Tank ID: T1: 87 Tank 1D: T2: 89 Z In-Tank Gauging Probe. Model: 847390-109 Z In-Tank Gauging Probe. Model: 847390-109 Z Annular Space or Vault Sensor. Model: 794390-409 Z Annular Space or Vault Sensor. Model: 794390-409 Z Piping Sump/Trench Sensor(s). Model: 794380-323 Z Piping Sump/Trench Sensor(s). Model: 794380-323 Z Fill Sump Sensor(s). Model: 794380-323 ®Fill Sump Sensor(s). Model: 794380-323 Z Mechanical Line Leak Detector. Model: R.J. XL ®Mechanical Line Leak Detector. Model: VMI 99 LD-2000 ❑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 type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: T3: 91 Tank ID: Z In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390-409 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-323 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: FE PETRO STP-MLD ❑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 type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser 1D: 1 &2 Dispenser ID: 3&4 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 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: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 ®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: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 ®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): Guadalaupe Sanchez Signature: Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Phone No.:(209) 845-8586 Testing Company Address: 521 Branding Iron Street, Oakdale CA 95361 Date of Testing/Servicing: 5/26/2010 Page 1 of 5 Rev(2/08)