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I IN 01 A I 1 11 <br />A. General Information <br />Facility Name: MoSsdale ArCo Date of Testing/Servicing: May 13, 2009 <br />Facility Address: 444 Mossdale Rd., Lathrop CA <br />Facility Contact Person: Nick Bokides Contact Phone No.: (209) 649-3808 LIA: <br />Make/Model of Monitoring System: Veeder-Root TLS -350 <br />B. Inventory of Equipment Tested/Certified: <br />E <br />Inspector: Muniappa Naidu <br />Check the appropriate boxes to Indicate specific equipment insffected/serviced <br />Tank ID: 87 Compartment <br />Tank ID: 91 Compartment <br />In -Tank Gauging Probe. Model: Mag 1 <br />0 In -Tank Gauging Probe. Model: Mag I <br />Annular Space or Vault Sensor. Model: 794390-420 (Shared) <br />0 Annular Space or Vault Sensor. Model: 794390-420 (Shared) <br />Piping Sump / Trench Sensor(s). Model: 794380-208 <br />Z Piping Sump / Trench Sensor(s). Model: 794380-208 <br />El Fill Sump Sensor(s). Model: <br />[:1 Fill Sump Sensor(s). Model: <br />21 Mechanical Line Leak Detector. Model: FE -Petro <br />0 Mechanical Line Leak Detector. Model: VMI 99LD-2000 <br />0 Electronic Line Leak Detector. Model: <br />El Electronic Line Leak Detector. Model: <br />0 Tank Overfill / High -Level Sensor. Model: OPW Drop Tube <br />Tank Overfill / High -Level Sensor. Model: OPW Drop Tube <br />Other <br />❑ Other <br />Tank ID: DSL Compartment <br />Tank ID: <br />10 <br />0 In -Tank Gauging Probe. Model: Mag I <br />El In -Tank Gauging Probe. Model: <br />0 Annular Space or Vault Sensor. Model: 794390-420 (Shared) <br />0 Annular Space or Vault Sensor. Model: <br />0 Piping Sump / Trench Sensor(s). Model: 794380-208 <br />0 Piping Sump / Trench Sensor(s). Model: <br />El Fill Sump Sensor(s). Model: <br />n Fill Sump Sensor(s). Model: <br />0 Mechanical Line Leak Detector. Model: VMI 99LD-2000 <br />0 Mechanical Line Leak Detector. Model: <br />❑ Electronic Line Leak Detector. Model: <br />El Electronic Line Leak Detector. Model: <br />Tank Overfill / High -Level Sensor. Model: Emco Drop Tube <br />El Tank Overfill / High -Level Sensor. Model: <br />Q Other <br />El Other <br />Dispenser ID. 1&2 Z Sump: ®Dry ®Water ®Product <br />Dispenser ID: 3&4 0 Sump: ®DryDWater ®Product <br />0 Dispenser Containment Sensor(s). Model: 794380-208 <br />0 Dispenser Containment Sensor(s). Model: 794380-208 <br />0 Shear Valve(s) (Functional test) <br />Shear Valve(s) (Functional test) <br />0 DiMenser Containment F12.As) and Chaj!gs). <br />❑ Dist)enser Containment Floats and Chain(EL,, <br />Dispenser ID: 5&6 Z Sump: ®Dry []Water []Product <br />Dispenser ID: 7&8 Z Sump: ®Dry ®Water ®Product <br />Dispenser Containment Sensor(s). Model: 794380-208 <br />0 Dispenser Containment Sensor(s). Model: 794380-208 <br />Shear Valve(s) (Functional test) <br />10 Shear Valve(s) (Functional test) <br />D Disl?enser Containment Float(s) and Chains 2._ <br />Q Di!Ecnser Containment 1712at�s) and Chain(s). <br />Dispenser ID: 9&10 0 Sump: ®Dry ®Water ®Product <br />Dispenser ID: I1&12 0 Sump: ®Dry []Water []Product <br />[0 Dispenser Containment Sensor(s). Model: 794380-208 <br />0 Dispenser Containment Sensor(s). Model: 794380-208 <br />Shear Valve(s) (Functional test) <br />0 Shear Valve(s) (Functional test) <br />❑ Di!genser Containment Float(s) and Chain(s2. <br />0 Di ser Containment Floats 2 and ChainUs . <br />C. Certification - I certify that the equipment identified in <br />this document was inspected/serviced in accordance with the <br />manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this <br />information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such <br />reports, I have also attached a copy of the report; (check all that apply): El System set-up El Alarm history report <br />Technician: <br />Date: 5/13/09 <br />Certification: Veeder-Root B36878, Level 2/3 <br />ICC UST Service Technician # 8005930 -UT <br />Page 1 of 3 06/05 <br />