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DD MONI*RING SYSTEM CERTIF ATI ON P For Use By All Jurisdictions Within the State of California 2008 Authority Cited: Chapter 6.7,Health and Safety Code;Chapter 16, Division 3, Title 23, California This form must be used to document testing and servicing of monitoring equipment. A separate certification or re o"k t &WM 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: TRACY TRUCK&AUTO STOP Bldg.No.: Site Address: 3940 N.Tracy Blvd City: Tracy Zip: 96376 Facility Contact Person: Debbie Jutla Contact Phone No.: (209) 832-5006 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 312612008 B. Inventory of Equipment Test Certified Check the aperopK!atc boxes to indicate sucific Squipment inspected/serviced: Tank ID: TI: 87 Unleaded Tank ED: T2:91 Supreme 0 In-Tank Gauging Probe. Model: El In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: PA02591144000 Annular Space or Vault Sensor. Model: PA02591 1"000 0 Piping Sump/Trench Sensor(s). Model: PA02592000010 Piping Sump/Trench Sensor(s). Model: PA02592000010 0 Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: VMl 991-0 2000 Mechanical Line Leak Detector. Model: VMI 2000 0 Electronic Line L&4&Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment toe and model in Section E on Page 2). 0 Other(Specify equipment type and model in Section E on Page 2). Tank ID: T3: Diesel 2 West Tank ID: T4: Diesel 2 East El In-Tank Gauging Probe. Model: [3 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: PA025911"000 Annular Space or Vault Sensor. Model: PA 02591144000 0 Piping Sump/Trench Sensor(s). Model: PA02692000010 Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: LD 3000-valve closed& Mechanical Line Leak Detector. Model: LD 3000 Mechanical Line Leak Detector. Model: not in use. ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1 +2 Dispenser ID: 3+4 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 'I0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ED: 5+6 Dispenser ID: 7+8 [I Dispenser Containment Sensor(s). Model: n Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Vaive(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 11 A Dispenser ID: 11 + 12A n Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: Shear Valve(s). 0 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). 0 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 alt that apply): System set-up 1Z Alarm history report Technician Name(print): Guadalupe Sanchez Signature: le 4A U Certification No.: A30138 License.No.: 883706 Testing Company Name: RELIABLE PETROLEUM SERVICES INC. Phone No.:(209) 846-8586 Testing Company Address: 621 Branding Iron St. Oakdale Ca.95361 Date of Testing/Servicing: 3/2612008_ Page I of (0 Rev(2/09,