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MONIORING 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 monitoringsystem 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 Jutla 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 thea ro riate boxes to indicate spEcific 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). Model: ❑Piping Sump/Trench Sensor(s). M ❑Fill Sump Sensor(s). el: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Det Model: ❑Mechanical Line Le ector. Model: ❑Electronic Line tector. Model: ❑Electronic L' ak Detector_ Model: ❑Tank /High-Level Sensor. Model: ❑Tan ell/High-Level Sensor. Model: er(specify equipment type and model in Section E on Page 2). (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. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensot(s). Model El Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). del: ❑Fill Sump Sensor(s)_ tEhanical Line Leak Model: ❑Mechanical Line Leak Detec Model: tronic Line tactor. Model: ❑Electronic Line actor. Model: /High-Level Sensor. Model: ❑Tank O /High-Level Sensor. Model: r(specify equipment type and model in Section E on Page 2). er(specify equipment type and model in Section E on Page 2). 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 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 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 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: 312612008 Page 3 of Rev(2/08)