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3 MONITORING SYSTEMCERTIFICATION For Use By All Jurisdictions Within the State of California Aiithorio%Cited:Chapter 6.?, Health and Sc fete Cocle; 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 2093 Bldg.No.: Site Address: 3425 Tracy Blvd. City: Tracy Zip: 95376 Facility Contact Person: (kabob Contact Phone No.: (209) 835-1605 Make/Model of Monitoring System: TLS350 Date of Testing/Servicing: 12/21/10 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: TanklD: 87#1 TanklD: 87#2 ®In-Tank Gauging Probe. Model: VR Mag Probe ®In-Tank Gauging Probe, Model: VR Mag Probe ®Annular Space or Vault Sensor. Model: VR 409 ®Annular Space or Vault Sensor. Model: VR 409 ®Piping Sump/Trench Sensor(s). Model: VR 323 Z Piping Sump/Trench Sensor(s). Model: VR 323 ®Fill Sump Sensor(s). Model: VR 323 Z Fill Sump Sensor(s). Model: VR 323 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: 848480 ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: Mag 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). Tank ID: 87#3 Tank ID: 91 ®In-Tank Gauging Probe. Model: VR Mag Probe Z In-Tank Gauging Probe. Model: VR Mag Probe ®Annular Space or Vault Sensor. Model: VR 409 ®Annular Space or Vault Sensor. Model: VR 409 ®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: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: 848480 ®Tank Overfill/Nigh-Level Sensor. Model: VR Mag Probe ®Tank Overfill/High-Level Sensor. Model: VR Mag Probe ❑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 ®Dispenser Containment Sensor(s). Model: VR 323 ®Dispenser Containment Sensor(s). Model: VR 323 ®Shear Valve(s).OPW Z Shear Valve(s).OPW ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ®Dispenser Containment Sensor(s). Model: VR 323 Z Dispenser Containment Sensor(s), Model: VR 323 Z Shear Valve(s).OPW Z Shear Valve(s).OPW ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)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): Brandon Smith Signature: —s Certification No.: A30746 License.No.: 300345-A HAZ C21 Testing Company Name: Wayne Perry Phone No.:(916) 646-9680 Site Address: 3425 Tracy Blvd.Tracy, CA Date of Testing/Servicing: 12/21/10 Page 1 of 4