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Sep 04 Q9 07:59a Reliable PetroleumA 209-845-8953 p.2 UNI RING SYSTEM CERTIFICATION 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 trust be used to document testing and servicing of monitoring equipment. A�eaarate certification or report must be prepared for each monitoring system controlpanel by the technician who performs the work. A copy of this form must be provided to the tank system ownerloperdtor. 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: PARKWOOD GAS&.FOOD )Bldg No.: Site Address: 1612 W. Hammer Lane City: Stockton Zip: 95206 Facility Contact Person: Pato Tiwana Contact Phone No.: (209) 482-2580 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 811112009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecirie a ui meat ins cted/serviced: FOAnnular : T-1 Supreme Tank ID: T-2 Unleaded nk Gauging Probe. Model: ❑In-Tank Ganging Probe. Model: Space or Vault Sensor. Model: PA02591144000 ®Annular Space or Vault Sensor. Model: PA02591144000 Sump/Trench Sensor(s), Model: PA0259 10 ®Piping Sump/Trench Senson(s), Model: PA02592000010 ❑Fill Sump Sensor(s). Model: ❑Fitt Sump Sensor(s). Model: ®Mechanical Line teak Detector. Model: 99 L02000 Z Mechanical Line Leak Detector. Model: 99�D2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Linc Leak Detector. Model.- 0 Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: T-3 Diesel Tank ID: ❑In-Tank Gauging Probe. Model: ❑to-Tank Gauging Probe, Model: Annular Space or Vault Sensor. Model: PA02591144000 ©Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sencor(s). Model: PA02592000010 ❑Piping Sump Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: LD 2000 Q Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section Eon Pa e 2 . ❑Tank Overfill?High-Levet Sensor. Model: g ) [I Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID: 314 I]Dispenser Containment Sensor(s). Model: i0 Dispenser Containment Sensw(s). Model: ®Shear Valve(s). ®Shear Valve(s). ®Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sertsor(s). Model: 794380-208 ®Shear Vatve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment FIoat(s)and Chain(s). Dispenser ID: Dispenser 11D: ❑Dispenser-Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(0 and Chain(s). *if the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser aa: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): Robert Barnhart Signature: fr�2��,1I" Certification No.: B35969 License.No.: 883706 Testing Company Name: Relllable Petroleum Service Inc. Phone No.:(209) 845-8586 Testing Company Address: 521 Branding.Iron Street, Oakland CA 95361 Date of Testing(Servicing: 81111 Page 1 of 4 U`-036—114 w»w.anidocs org Rev.01117lpg