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IVMRECENIT NG SYSTEM CERTIFI TION 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 NO'd 4 2010 ibis form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be pEWared for each JVA tno ' control 1 by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. Theo py of this form to the local agency regulating UST systems within 30 days of test date. /SERVICES A. General Information Facility Name: Arco Bldg.No.: Site Ad Joe Pombo,Parkway City: Tracy Zip: 95376 Facility Contact Person: Ranjeet Singh Contact Phone No.: (209) 579-4014 MaketModel of Monitoring System: Veeder Root TLS 3W Date of Testing/Servicing: 10119/2010 B. Inventory of Equipment Tested/Certified Check thea to boxes to indicates 'fce!quipeent i se . Tank : T-1 87 Master FAnnular 2 87 Syphon ®In Tank : 109 'ng Model: 149 ®Annular or Vault M or Vault Model: 409 ®Piping Sump/Tnech s). : 323 1 T s). Model: 323 ®Fill Sump s). : 323 ®Fill Sump Sensor(s). Model: 323 ❑Mechanical Line Leak erector. M ❑Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 8484 ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Uvel Sensor Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment tylce and model in Section E on Page 2). ❑Other(specify equipment type and modd in Section E on Page 2). Tank ID: T-3 91 Tank ID: ®In-Tank Gauging Probe Model: 109 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault ❑Annular Space or Vault Sensor. Model: ®Piping S /T s). Model: 323 ❑Piping Sump/Trench Sensor(s). Model: ®Fill s). Model: 323 ❑Fill Sump s). Model: ❑Mechanical ❑Mechanical Line Leak Detector. Madel: ®Electronic Luce Leak Detector M ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level ❑Tank Overffil/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). Dispenser ID: 112 Dispenser ID: 314 ® s). Model: 323 0 Dispenser Containment Sensor(s). Model: 323 ®Shear Valve(s). 0 Shear Valve(s). ❑Dispenser' t s) s) ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ®Dispenser Containment s). 1: 323 ®Dispenser Containment Sensor(s). Model: 323 ®Shea Valve(s). ®Shear Valve(s). ❑DLV=w Containment s)and s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9110 Dis ser ID: 11112 ®Dispenser Con s). : 323 0 Dispenser Containnient Sensor(s). Model: 323 ®Shear Valve(s). Shear Valve(s)_ ❑Dispenser Containment s)and Chmn(s). ❑Dispenser menu 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 ins serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e g. ufacturers' checklists) necessary to verify that this information is correct and a Plot Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the rt;(check all that ): ®System set-up Alarm history report Technician Naive(print): Guadalupe Sanchez Signature: Certification No.: X430138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services,Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Date of Testing/Servicing: 10/19/2010 Page 1 of 4 Rev(2/08)