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A. General Information Facility Name: Hammer 1-5 Arco Date of Testing/Servicing: 8/22/11 Facility Address: 3250 Hammer Lane, Stockton CA 95209 Facility Contact Person: Wes Parkinson Contact Phone No.: 474-9125 Regulatory agency: San Joaquin Health; Inspector: Garrett Backus; Phone: 468-9847; Fax 468-3433 Make/Model of Monitoring System: Veeder- Root TLS -350 3. Inventory of Equipment Tested/Certified: Tank ID: 87A ®In -Tank Gauging Probe. Model: Mag 1 ®Annular Space or Vault Sensor. Model: 794390-409 N Piping Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: NONE ®Mechanical Line Leak Detector. Model: Red Jacket ❑Electronic Line Leak Detector. Model: NONE NTank Overfill / High -Level Sensor. Model: Drop Tube N Fillspill buckets tested ❑Pass ❑Fail Tank ID: 91 Nln-Tank Gauging Probe. Model: Mag 1 ®Annular Space or Vault Sensor. Model: 794390-409 ®Piping Sump Sensor(s). Model: 794380-208 []Fill Sump Sensor(s). Model: NONE ®Mechanical Line Leak Detector. Model: FE Petro ❑Electronic Line Leak Detector. Model: NONE NTank Overfill / High -Level Sensor. Model: Drop Tube N Fillspill buckets tested NPass ❑Fail Vapor Condensate Sump: NDry []Water ❑Product N Sensor(s). Model: 794380-208 Dispenser ID: 1&2 N Sump: NDry ❑Water ❑Product N Dispenser Containment Model: Float and Chain ®Shear Valve(s) (Functional test) ®Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5&6 N Sump: NDry ❑Water ❑Product N Dispenser Containment Model: Float and Chain ®Shear Valve(s) (Functional test) ®Dispenser Containment Float(s) and Chain(s). Tank ID: 87B ®In -Tank Gauging Probe. Model: Mag 1 ®Annular Space or Vault Sensor. Model: 794390-409 ®Piping Sump Sensor(s). Model: 794380-208 El Fill Sump Sensor(s). Model: NONE F1 Mechanical Line Leak Detector. Model: Shared ❑Electronic Line Leak Detector. Model: NONE ®Tank Overfill / High -Level Sensor. Model: Drop Tube N Fillspill buckets tested NPass ❑Fail Tank ID: ❑ In -Tank Gauging Probe. Model: []Annular Space or Vault Sensor. Model: ❑Piping Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: F] Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill / High -Level Sensor. Model: ❑ Fillspill buckets tested ❑Pass ❑Fail Piping Transition Sump: NDry ❑Water ❑Product N Sensor(s). Model: 794380-208 Dispenser ID: 3&4 N Sump: NDry ❑Water ❑Product N Dispenser Containment Model: Float and Chain ®Shear Valve(s) (Functional test) ®Dispenser Containment Float(s) and Chain(s). Dispenser ID: 7&8 N Sump: NDry ❑Water ❑Product N Dispenser Containment Model: Float and Chain ®Shear Valve(s) (Functional test) ®Dispenser Containment Float(s) and Chain(s). 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): N System set-up N Alarm history report Signature of Technician: � rtif_ication:j ICC UST Technician # 8005930 -UT Veeder Root # B36878 Level 4 ISD Date: 8/22/11 P.O. Box 4208 Sonora CA 95370 A tec Petr Ca: 209-53 -7320 Phone: 209-532-7320 Compliance without Compromise Fax: 209-533-2650 MONITORING SYSTEM CERTIFICATION mail@alltechpetro.com www.alitechpetro.com A. General Information Facility Name: Hammer 1-5 Arco Date of Testing/Servicing: 8/22/11 Facility Address: 3250 Hammer Lane, Stockton CA 95209 Facility Contact Person: Wes Parkinson Contact Phone No.: 474-9125 Regulatory agency: San Joaquin Health; Inspector: Garrett Backus; Phone: 468-9847; Fax 468-3433 Make/Model of Monitoring System: Veeder- Root TLS -350 3. Inventory of Equipment Tested/Certified: Tank ID: 87A ®In -Tank Gauging Probe. Model: Mag 1 ®Annular Space or Vault Sensor. Model: 794390-409 N Piping Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: NONE ®Mechanical Line Leak Detector. Model: Red Jacket ❑Electronic Line Leak Detector. Model: NONE NTank Overfill / High -Level Sensor. Model: Drop Tube N Fillspill buckets tested ❑Pass ❑Fail Tank ID: 91 Nln-Tank Gauging Probe. Model: Mag 1 ®Annular Space or Vault Sensor. Model: 794390-409 ®Piping Sump Sensor(s). Model: 794380-208 []Fill Sump Sensor(s). Model: NONE ®Mechanical Line Leak Detector. Model: FE Petro ❑Electronic Line Leak Detector. Model: NONE NTank Overfill / High -Level Sensor. Model: Drop Tube N Fillspill buckets tested NPass ❑Fail Vapor Condensate Sump: NDry []Water ❑Product N Sensor(s). Model: 794380-208 Dispenser ID: 1&2 N Sump: NDry ❑Water ❑Product N Dispenser Containment Model: Float and Chain ®Shear Valve(s) (Functional test) ®Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5&6 N Sump: NDry ❑Water ❑Product N Dispenser Containment Model: Float and Chain ®Shear Valve(s) (Functional test) ®Dispenser Containment Float(s) and Chain(s). Tank ID: 87B ®In -Tank Gauging Probe. Model: Mag 1 ®Annular Space or Vault Sensor. Model: 794390-409 ®Piping Sump Sensor(s). Model: 794380-208 El Fill Sump Sensor(s). Model: NONE F1 Mechanical Line Leak Detector. Model: Shared ❑Electronic Line Leak Detector. Model: NONE ®Tank Overfill / High -Level Sensor. Model: Drop Tube N Fillspill buckets tested NPass ❑Fail Tank ID: ❑ In -Tank Gauging Probe. Model: []Annular Space or Vault Sensor. Model: ❑Piping Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: F] Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill / High -Level Sensor. Model: ❑ Fillspill buckets tested ❑Pass ❑Fail Piping Transition Sump: NDry ❑Water ❑Product N Sensor(s). Model: 794380-208 Dispenser ID: 3&4 N Sump: NDry ❑Water ❑Product N Dispenser Containment Model: Float and Chain ®Shear Valve(s) (Functional test) ®Dispenser Containment Float(s) and Chain(s). Dispenser ID: 7&8 N Sump: NDry ❑Water ❑Product N Dispenser Containment Model: Float and Chain ®Shear Valve(s) (Functional test) ®Dispenser Containment Float(s) and Chain(s). 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): N System set-up N Alarm history report Signature of Technician: � rtif_ication:j ICC UST Technician # 8005930 -UT Veeder Root # B36878 Level 4 ISD Date: 8/22/11