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Monitoring System Equipment Certification For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6. ? 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: C*1 e V k_� Bldg. No.: Site Address: 10858 Trinity Pkwy City: Stockton, CA Zip: 95219 - Facility Contact Person: Manager Contact Phone No.: (209) 952-2213 Make/Model of Monitoring System: V/R TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 5/14110 Tank ID: 01-Regu Tank ID: 02 -Prem [3 In - Tank Gauging Probe. Model: VR 847390-109 (3 In - Tank Gauging Probe. Model:VR 847390-109 fd Annular Space or Vault Sensor. Model: VR 794380-303 pj Annular Space or Vault Sensor. Model VR 794390-303 IX Piping Sump \ Trench Sensor (s). Model- VR 794380-208 13 Piping Sump \ Trench Sensor (s). Model: VR 794380.208 IS Fill Sump Sensor (s). Model: VR 794380-20e [3 Fill Sump Sensor (s). Model: VR 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: (3 Electronic Line Leak Detector. Model: VR series 8484 13 Electronic Line Leak Detector. Model: VR series a484 ❑ 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: VR 847390-109 ❑ In - Tank Gauging Probe. Model: la Annular Space or Vault Sensor. Model: VR 794390-303 ❑ Annular Space or Vault Sensor. Model: Piping Sump \ Trench Sensor (s). Model: VR 794380-20e ❑ Piping Sump \ Trench Sensor (s). Model: Fill Sump Sensor (s). Model: VR 794380-20e ❑ Fill Sump Sensor (s). Model- ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: VR series 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). ❑ Other ( specify equipment type and model in Section E on Page 2). Dispenser ID: 01-02 Dispenser ID: 03.04 Dispenser Containment Sensor (s). Model: VR 794380-20e [3 Dispenser Containment Sensor (s). Model: VR 794380.208 QI Shear Valve (s). 13 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 05-06 Dispenser ID: 07-06 is Dispenser Containment Sensor (s). Model: VR 794380.208 (3 Dispenser Containment Sensor (s). Model: VR 794380-208 fd Shear Valve (s). Q( 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 2 Dispenser Containment Sensor (s). Model: VR 794380-208 11 (3 Dispenser Containment Sensor (s). Model: VR 794330-208 Cd Shear Valve (s). (3 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). .11 ❑ Dispenser Containment Float (s) and Chain (s). the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility C. Certification - 1 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, 1 have also attached a copy of the-, ( check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Jerry Sanouyong 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: 5/14110