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e t MON14MNG SYSTEMCIFI 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 Re ,{tgns- This form must be used to document testing and servicing of monitoring equipment. A separate certification or re - ��sd. c 1 f'bf'each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date CT 1 1 X008 A. General Information - Facility Name: ARCO AM PM#82602 Site Address: 2430 Joe Pombo Parkway City: Tracy Zip: 95376 Facility Contact Person: Ranjeet Singh Contact Phone No.: (209) 579-4014 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 10/9/2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins eeted/serviced: Tank ID: T1: 87 Master Tank iD: T2: 87 Slave Z in-Tank Gauging Probe. Model: 847390-109 ®In-Tank Gauging Probe. Model: 847390409 Z Annular Space or Vault Sensor. Model: 794390-409 ®Annular Space or Vault Sensor. Model: 794390-409 Z Piping Sump/Trench Sensor(s). Model: 794380-323 ®Piping Sump/Trench Sensor(s)_ Model: 794380-323 Z Fill Sump Sensor(s). Model: 794380-323 Z Fill Sump Sensor(s). Model: 794380-323 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: 8484 ®Electronic Line Leak Detector. Model: 8484 ❑Tank Overfill/High-Level Sensor. Model: AN @ 90% ❑Tank Overfill/High-Level Sensor. Model: AN @ 90% ❑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: T3: 91 Tank ID: ®In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390-409 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-323 ❑Piping Sump/Trench Sensor(s)- Model: Z Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: 8484 ❑Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: AN @ 90% ❑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). Dispenser ID: 112 Dispenser ID: 3 14 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ®Dispenser Containment Sensor(s). Model: 794380-323 ®Dispenser Containment Sensor(s). Model- 794380-323 ®Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9110 Dispenser ID: 11 112 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑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 Z Alarm history report ' / Technician Name(print): Guadalupe Sanchez S* tui Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Phone No.:(209) 845-8586 Testing Company Address: 521 Branding Iron St. Oakdale Ca.95361 Date of Testing/Servicing: 10/9/2008 Page 1 of 4 Rev(2/08)