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WO -8286 RECEIVED MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California SEP 1 1 2017 A uthori1j,, Cited: Chapter 6.7, Health and Safety Code,- Chapter 16, Division 3, Title 23, Calijbi-nia Code ot'Regulations ENVIRO Thisform m must be used to document testing and servicing of monitoring equipment. A separate certification or renortinikst e- - control panel by the technician who performs the work. A copy of this form must be provided to the tan OINtU, ato1% The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test dale. A. General Information Facility Name: United Pacific 5447 Site Address: 1409 E. Hammer Ln. Facility Contact Person: Make[Model of Monitoring System.. Feeder -Root TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate socciric vouimnent insoected/serviced: Bldg. No.: City: Stockton Zip: 95210 Contact Phone No.: Date of Testing/Servicing: 9/W2017 Tank [D: Diesel Tank ID: C1 In -Tank Ganging Probc. Model: 0 In -Tank (.3anging Probe. model; E] Annular Space or Vault SCIISOr. Model: 794390-409 0 Annular Space or Vault Sensor. Model: 0 Piping Snap: Trench Sensor(s). Model: 0 Piping Sunip I Trench Sensoo .4 Model: F-1 Fill Sunip Sensor(,). Model: Q fill Sump Sensor(s). Model- [] Mechanical Line Leak Doccior, Model: Q Mechanical Line Leak Detector. Model: El Fivch-onic Line Leak Detector. Model: Q Electronic Line Leak Detector. Model; nTank Overfill A ligh-Level Sensor. Model: Q *rank Overfill i lligh-Level Sensor. Model; usher {specify equipment type and model in Section E on Page 2). E] Other ispecify equipment type and model in Section E,,n Ngk! 2). Tank ID: Tank ID: ❑ In -Tank Ganging Probe Model: Fl In -Tank Gauging Probe. Model: E] Ainuilar Space or Vault Sensor. Model: n Annular Space or Vault Sensor, Model: Piping Sunip /1'rench Sensor(s). Model: Q Piping Sump i Trench Serigor(s), Model: Fill Sunip scilsol(s). Model: Q Fill Sunip Sensor(s), Model: ❑ Nicchanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑ Flectronic Line Leak Detector. Model: C] Tank Overfill I I ligh-Level Sensor. Model: ❑ Tank Overfill i High -Level Sensor. Model: Other {specify equipment type and model in Section E on Page 2). Q Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: Model: C]Dispeti.serCotitaiiiinctitSciisot-(.i). Model: El Shear Valvc(0' [:] Shear Valve($). [:]Dislicii,ei-Ct)iiiaiiiiiiciiI Float(s) and Chain(s). C]Dispensei-Containment Float(s)and (liaiiiis), r Dispenser ID: Dispenser ID: E] 11 l('0anunew Solsolf S). Model-. Containment Coatainent Sensor(g). Model. Shear Valve(O. 0 - , M Shear ValveW. 0 Cl Dispenser Containnicat Floats) and Chain(s), E] Dispenser Containment Float(s) and Chaini s). Dispenser ID: Dispenser ID: Model: r-lDispeti.ierCotitaiiimetitSciisoi,(s). Model: ❑Shear Vill vc(s). ❑Shear Valvos'). Dispenset a'(.') and Coll ta inniclit and Chain(-;). Dispenser Containment Float(s) and Chaiji(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): [E]Systein set-up [:]A1arrn history report Technician Name (print): Pat Armour Certification No.: A20294, 8141940-ur Signature: License. No.: 498721 Testing Company Name: Armour Petroleum Service & Equipment Corporation Phone No.: (707) 437-6668 Testing Compaii.NAddress: 2400 Cement Hill Rd.. B3, Fairfield, CA 94533 Page I of 3 Date of Testing/Servicing: 916/2017 Rev (2/08)