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MONI' )RING SYSTEM CERTIF ATION 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 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 AM PM Site Address: 1711 E. Yosemite AvenueCity: Manteca Zip: 95336 Bldg.No.: Facility Contact Person: Paul Singh Contact Phone No.: (209) 8234715 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 5/26/2010 B. Inventory of Equipment Tested/Certified Check the apprODriate boxes to indicatespecific a ui ment inspected/ser-viced: 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: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). El Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: ❑]n-Tank Gauging Probe. Model: Tank ID: ❑Annular Space or Vault Sensor. Model: [I In-Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ ❑Tank Overfill/High-Level Sensor. Model: Electronic Line Leak Detector. Model: ❑Other(specify equipment type and model in Section E on Page 2). Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 13& 14 ®Dispenser Containment Sensor(s). Model: 794380-323 Dispenser ID: lin 8c 16 ®Dispenser Containment Sensor(s). ®Shear Valve(s). Model: 794380-323 El Dispenser Containment Float(s)and Chain(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Float(s)and Chain(s). ❑Shear Valve(s). ❑ Dispenser ID: Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Sensor(s). Model: Dispenser ID: ❑Shear Valve(s). [I Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Float(s)and Chain(s). ❑Shear Valve(s). Dispenser Containment Float(s) *If the facility contains more tanks or dispensers,copy this form. Include information for every tank anddispen erdat(the facility. C. Certification -1 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. Testing Company Address: 521 Branding Iron Street, Oakdale CA 95361 Phone No.:(209) 845-8586 Date of Testing/Servicing: 5/26/2010 Page 2 of 5 Rev(2/08)