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°MONIARING SYSTEM CER 1 IF ATI®N 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 BP 2133 Site Address: 2908 Beniamin Holt Bldg. No.: City: Stockton Zip: 95207 Facility Contact Person: Not reported Contact Phone No.: (209) 478-5552 Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 4/5/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate saecitic equipment inspected/serviced: Tank ID: 87 main Tank ID: 87 aux N In -Tank Gauging Probe. Model: mag probe ® In -Tank Gauging Probe. Model: mag probe N Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 N Piping Sump / Trench Sensor(s). Model: 323 ® Piping Sump / Trench Sensor(s). Model: 323 N Fill Sump Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 323 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector. Model: plld 157879 ❑ Electronic Line Leak Detector. Model: N Tank Overfill / High -Level Sensor. Model: probe N Tank Overfill / High -Level Sensor. Model: probe ❑ Other (specify equipment type and model in Section E on Page 2). N Other (specify equipment type and model in Section E on Page 2). Tank ID: 91 Tank ID: N In -Tank Gauging Probe. Model: mag probe ❑ In -Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: N Piping Sump / Trench Sensor(s). Model: 323 ❑ Piping Sump / Trench Sensor(s). Model: N Fill Sump Sensor(s). Model: 323 ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: vmi-Id2000 (not tested) ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Tank Overfill / High -Level Sensor. Model: probe ❑ 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 N Dispenser Containment Sensor(s). Model: 323 N Dispenser Containment Sensor(s). Model: 323 N Shear Valve(s).opw-2 N Shear Valve(s). opw-2 ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser 1D: 5/6 Dispenser ID: 7/8 N Dispenser Containment Sensor(s). Model: 323 N Dispenser Containment Sensor(s). Model: 323 N Shear Valve(s).opw-2 N Shear Valve(s).opw-2 ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: transition sump Dispenser ID: vapor pot N Dispenser Containment Sensor(s). Model: 323 N Dispenser Containment Sensor(s). Model: 323 ❑ Shear Valve(s). ❑ 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): Omar Ruiz Certification No.: B35686 Signature: License. No.: 794519-A HAZ C21 Testing Company Name: Fueling & Service Tech., Inc. (FASTECH) Phone No.: (714) 523-0194 Site Address: 7050 Village Drive, Suite D, Buena Park, CA 90621 Date of Testing/Servicing: 4/5/2011 Page 1 of 4