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MONI*VRINse SYSTEM CERTIF 10ATION 0 F6 se By All Jurisdictions Within the State of Cal�rornia Authority Cited: Chapter 0.7, 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 rt-must be for each monitoring system control panel by the technician who performs the work. A copy of this form must be provi e operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 day A. General Information Facility Name: PARKWOOD GAS&FOOD AUG '1 9009 Site Address: 1612 W. Hammer Lane City: Stockton ---Tr MTV t� 401. Facility Contact Person: Paul Tiwana Contact Phone No. 4 -igild,- Make/Model of Monitoring System: Glibarco EMC Date of Testing/Servicing: 811112009 B. Inventory of Equipment Tested/Certified Ch ec k t h e a o n i a t e b o x e s to indicates -e-e--d-I -- c--e-quienent ins -ctew1serviced ; Tank ID: T-1 Supreme Tank D : T-2 Unleaded0 in-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model::AnnuIar Space or Vault Sensor. Model: PA025911440 Annular Space or Vault Sensor. Model: --PA-0�26911M � 00Piping Sump/Trench Sensor(s). Model: PA02592000010 0 Piping Sump/Trench Sensor(s). Model: PA025920100 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model:9 Mechanical Line Leak Detector. Model: 99 LD2000 0 Mechanical Line Leak Detector. Model: 99 LD20000 Electronic Line Leak Detector. Model: EElectronic Line Leak Detector. Model: 0 TanOverfill High-Level Sensor. Model: 0 Tank Overfill High-Level Sensor, Model: 0 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 D: T-3 Diesel Tank E :0In-Tank Gauging Probe. Model: EIn-Tank Gauging Probe. Model:Annular Space or Vault Sensor. Model: PA02591140 EAnnular Space or Vault Sensor. Model:Piping Sump/Trench Sensor(s). Model: PA02692000010 0 Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LD 2000 — 11 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: n Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2). 0 Other I (specify equipment type and model in Section E on Page 2). Dispenser 101 112 0 Dispenser Containment Sensor(s). Model: Dispenser ID:-3/6 F1 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s), 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Mmmmmmmml ---------- Dispenser ID: 7/8 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). 0 Dispenser i Dispenser s s Dispenser Dispenser D Shear e .-s Dispenser n p p Other s e er e r V er pens Oth pe' ear u. 1 i's nss ep r Valve(s), r D IDC e C er C 0 0 s y Containment Containment Shear Valve(s). Model: Dispenser Containment Float(s)and Chain(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). FDispenser ID: 0 C Dispenser ID: Dispenser U 0 Dispenser Containment sensor(s). Model: 0 Shear V Iv () 0 Dispenser Containment Sensor(s). El Shear Valve(s). Model: Dispenser r Cont, El Shear Valve(s), Dispenser Containment Float(s),and Chain(s). El 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): Robert Barnhart Signature: Certification No.: B36969 Testing Company Name: Reliable Petroleum Service Inc. License.No.: 883 06 Testing Company Address: 521 Branding Iron Street, Oakland CA 95361 Phone No.:(209) "S-8586 Date Of Testing/Servicing: 8/11/2 Page 1 of 4 UN-036-114 www.unidomorg Rev.01/17/08