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I*RING SYSTEM CERTIFOATION 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_Wstem 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: 95376 Facility Contact Person: Debbie Jutia Contact Phone No.: (209) 832-5006 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 3/26/2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ted/serviced: Tank ID: Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model- ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). M ❑Piping Sump/Trench Sensor(s). M ❑Fill Sump Sensoriaecto,.r Model: ❑Fill Sump Sensor(s). Model- ®Mechanical Line eo. Model: ❑Mechanical Line Leak ector. Model: ❑Electronic Lin Model: ❑Electronic Li ak Detector. Model: ❑Tank II/High-Level Sensor. Model: ❑Tanill/High-Level Sensor. Model: er(specify equipment type and model in Section E on Page 2). er(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Mode• ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). odel: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). el: ❑Mechanical Line tector. Model: ❑Mechanical Line Leak Det Model: ❑Electronic ' e Leak Detector. Model: ❑Electronic Line tector. Model: ❑T erfill/High-Level Sensor. Model: ❑Tank Ov /High-Level Sensor. Model• er(specify equipment type and model in Section E on Page 2). ❑ r(specify equipment type and model in Section E on Page 2). Dispenser ID: 12+ 13A Dispenser : 15+ 16A ❑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 Float(s)and Chain(s). Dispenser ID: 14+ 15A Dispenser : 7+8 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ®Shear Valve(s). ®Dispenser Containment Float(s)and Cham(s). ®Dispenser Containment Float(s)and Chain(s). Dispenser ID: 16+ 17A Dispenser ID: 17+ 18A ❑Dispenser Containment Sensor(s). Model: ❑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). *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): Guadalupe Sanchez Signature: Certification No.: A30138 License.No.: 883706 Testing Company Name: RELIABLE PETROLEUM SERVICES INC. Phone No.:(209) -8586 Testing Company Address: 521 Branding Iron St. Oakdale Ca.95361 Date of Testing/Servicing: 3/26/2008 Page 2 of Rev(2/08,