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MONARING SYSTEM CERT1F#ATI 0VR087,,-`�r/�'`'For Use By All Jurisdictions Within the State of California Authority Cited.-Chapter 6 7,Health and Safe Code,tyChapter 16,Division 3, Title 23CaliforniaAUyojRg,4ati This form must be used to document testing and servicing of monitoring equipment. A separate cc ification o rennd for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided I rator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within '(fILW/ i 30 days of test a . A. General Information 1IRMICE6, Facility Name: ARCO AM PM#82602 Bldg.No.: Site Address: 2430 Joe Pombo parkway City: Tracy CA Zip: 95377 Facility Contact Person: Raqjeet Singh Contact Phone No.: f209 -401A4 Make/Model of Monitoring System: Veeder Root TLS-350 ) 579 Date of Testing/Servicing: 1012112009 B. Inventory of Equipment Tested/Certified Check the a2propriate boxes to indicates ecifle!Suipment insmtcd/serviced: Tank ID: TI: Master Tank in T2: Slave M TIn-Tank Gauging Probe. Model: 847390-109 in-Tank—Gauging Probe. Model: 847390-109 Annular Space or Vault Sensor. Model: 794390-409 Annular Space or Vault Sensor. Model: 794390-409 Piping Sump/Trench Sensor(s). Model: 794380-323 Piping Sump/Trench Sensor(s). Model: 794380-323 ®Fill Sump Sensor(s). Model: 794380-323 Fill Sump Sensor(s). Model: 794380-323 El Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 8484 0 Electronic Line Leak Detector. Model: 8484 n Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Scction E on Page 2). n Other(specify equipment type and model in Section E on Page 2). Tank ID: T3: 91 Tank ID: In-Tank Gauging Probe. Model: 847390-I09 [I In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 7943 09 F-1 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 794380.323 [1 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 794380-323 El Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: n Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 8484 0 Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 0 Dispenser Containment Sensor(s). Model: 794380-323 0 Dispenser Containment Sensor(s). Model: 794380-323 N Shear Valve(s). 0 Shear Valve(s). C]Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). NENMNEW� Dispenser ID: 616 Dispenser ID: 718 Dispenser Containment Sensor(s). Model: 79M0-323 0 Dispenser Containment Sensor(s). Model: 794380-323 Shear Valve(s). 21 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). go Dispenser ID: 9/10 Dispenser ID; 11/12 Dispenser Containment Sensor(s). Model: 794380-323 0 Dispenser Containment Sensor(s). Model: 794380-323 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 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 uipment. For any eq ment capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up 2 Alarm history rt Technician Name(print): Robert Barnhart Signature:A,�-LO47, Certification No.: 835969 License.No.: 8d3706 L, Testing Company Name: Reliable Petroleum Service Inc. Phone No.:(209) 845-8586 Testing Company Address: 521 Branding Iron Street, Oakdale CA 96361 Date of Testing/Servicing: 10/21/2009 Page 1 of 4 UN-036-1/4 www.unidoes.org Rev.01/17/Q8