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Work Order: 2275500 Monitoring System Equipment 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 must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for 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 system within 30 days of test date. A. General Information FacilityName: 'S Q 7 -7 U I Bldg. No.: Site Address: 10858 Trinity Pkwy City: Stockton, CA Zip: 95219 - Facility Contact Person: Manager Contact Phone No.: A209) 952-2213 Make/Model of Monitoring System: V/R TLS -350 Date of Testing/Servicing: 5/14110 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 01-Regu Tank ID• 02 -Prem IN In - Tank Gauging Probe. Model: VR 847390-109 13 In - Tank Gauging Probe. Model: VR 847390-10e QI Annular Space or Vault Sensor. Model: VR 794380-303 GI Annular Space or Vault Sensor. Model: VR 794380-303 pI Piping Sump \ Trench Sensor (s). Model: VR 794M.20e 13 Piping Sump \ Trench Sensor (s). Model: VR 794380-208 QI Fill Sump Sensor (s). Model: VR 794380.208 13 Fill Sump Sensor (s). Model: VR 794380-703 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 15 Electronic Line Leak Detector. Model: VR Series 8484 IN Electronic Line Leak Detector. Model: VR Sens, 8484 ❑ 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: 03 -Diesel Tank ID: ❑ In - Tank Gauging Probe. Model: � In - Tank Gauging Probe. Model: VR 847390-109 Q Annular Space or Vault Sensor. Model: VR 7943110-303 ❑ Annular Space or Vault Sensor. Model: Q Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ❑ Piping Sump \ Trench Sensor (s). Model: IE Fill Sump Sensor (s). Model: VR 794380-208 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: la Electronic Line Leak Detector. Model: VR sena. 8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 2). p Others equipment (peci fy type and model in Section E on Page 2). Dispenser ID: 01.02 Dispenser ID' 03-04 B Dispenser Containment Sensor (s). Model: VR 7943410-208 ra Dispenser Containment Sensor (s). Model: VR 794380.208 2 Shear Valve (s). QI Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 05-06 Dispenser ID: 07-08 Dispenser Containment Sensor (s). Model: VR 79830.203 fX Dispenser Containment Sensor (s). Model: VR 794380-208 3 Shear Valve (s). M Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 09-10 Dispenser ID: 11-12 • Dispenser Containment Sensor (s). Model: VR 794380.208 (9 Dispenser Containment Sensor (s). Model: VR 794380.208 • Shear Valve (s). QI Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). w, mb uivrc ran cs or umspensers, copy tats tone. 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 manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures' 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; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Jerry Sanouvong Signature: Mfg. Cert.#.: B37362 ICC# 8020732 -UT License. No.: 485184 Testing Company Name: Serv. Sta. Sys. Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 5114110 Tanknology Inc. 11000N. MoPac Expressway, Suite 500, Austin, Texas 78759