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t a MONITORING SYSTEM CERTIFICATION I 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 6080 Bldg.No: Site Address: 85 Louise Ave City: I Lathrop zip: 95330 j Facility Contact Person: I Rahim Contact Phone No.: 1 209-983-9144 Make/Model of Monitoring System: 1 Veeder Root TLS 350 Date of Testing/Servicing: 1 8-24-10 S. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment inspected/serviced: Tank 1D: Tank 1 Unleaded Tank ID: Tank 2 Mid rade ®In-Tank Gauging Probe. Model: 847390 ®In-Tank Gauging Probe. Model: 847390 ®Annular Space or Vault Sensor. Model: 794380-302 ®Annular Space or Vault Sensor. Model: 794380-302 ®Piping Sump/Trench Sensor(s). Model: VR 323 ®Piping Sump/Trench Sensor(s). Model: VR 323 ®Fill Sump Sensor(s). Model: VR 323 ®Fill Sump Sensor(s). Model: VR 323 ®Mechanical Line Leak Detector. Model: RJ65 ®Mechanical Line Leak Detector. Model: RJ65 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/Nigh-Level Sensor. Model: 790091-001 ®Tank Overfill/High-Level Sensor. Model: 790091-001 ❑Other(s ecif equipment e and model in Section E on Page 2). ❑Other(s ecifv e ui meat a and model in Section E on Page 2). Tank ID: Tank 3 Premium Tank ID: ®In-Tank Gauging Probe. Model: 847390 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794380-302 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: VR 323 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: VR 323 ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: RJ65 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/high-Level Sensor. Model: 790091-001 ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Pae 2). ❑Others eci a ui meat type and model in Section E on Pae 2). Dispenser Ill: 1/2 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s), Model: 794390-323 ®Dispenser Containment Sensor(s). Model: 794390-323 ® Shear Valve(s). ❑Check if no shear valves are present ®Shear Valve(s). ❑Check if no shear valves are present ❑Dis)enser Containment Float(s)and Chain(s). ®NA ❑Dispenser Containment Float(s)and Chain(s). ®NA Dispenser ID: 5/6 Dispenser ID: 7/8 ®Dispenser Containment Sensor(s). Model: 794390-323 ®Dispenser Containment Sensor(s). Model: 794390-323 ®Shear Valvc(s). ❑Check if no shear valves are present ®Shear Valve(s). ❑Check if no shear valves are present ❑Dispenser Containment Flont(s)and Chain(s). ®NA ❑Dispenser Containment Float(s)and Chain(s). ®NA Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Check if no shear valves are present ❑Shear Valve(s). ❑Check if no shear valves are present ❑Dispenser Containment Float(s)and Chain(s). ❑NA ❑Dispenser Containment Float(s)and Chain(s). ❑NA •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 inlorntation (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): Don Hicks Signature: &G� Certification No.: A25125 License No.: 300345 IV Testing Company Name: Wayne Perry Inc. Phone No.: 916-646-9680 Site Address: Street: 85 Louise City: Lathrop Zip: 95330 Date of Testing/Service: 8-24-10 Page 1 of 4