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: Monitoring •System Equipment Certification For Use By All Jurisdictions Within The Stale gl'C'al#brnia Authorih, Cited: Chapter 67, Health and Safe -Code: Chapter 16, Division 3. Title 23. C'alilnrnia Code ul'Regulwions be Chis form must be used to document testing and servicing of monitoring equipment. A separate certification or report must o vided r`'d for each monitoring system control panel by the technician who performs the work. A copy of this form must be pro � Io 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 Facility Name: Chev 307709 Bldg. No.: bite" Address: 10858 Trinity Pkwy @ Scott Creek Dr. _ city -.Stockton, CA Zip: 95219- •- ' Facility Contact Person: Contact Phone No.: (209) 952-2213 Make/Model of Monitoring System: V/R TLS -350 Date of'I'esting'Servicing: 12/11/09 ti B. Inventory of Equipment Tested/Certified Check the ropprupriate Moves to indicate specific equipment I nspectetV%cry iced: 11 the the f@cility contains more tanks or dispensers. copt, this Corm. Include inti%mtauun fr ix cery tank and dispenser at the tacobn (. CertifiCation 1 certify that the equipment identified in this document %vas inspected/serviced in accordance with the in guidelines. Attached to this Certification is information (ag. manufactures checklists) necessary to verify that this information is correct and a Plot Plan showin8 the layout of monitoring equipment, for any equipment capable of generating such rellVlifa:lltr>ivf t11 6�tttached a copy of the. ( check rill than npplv): f� tiystetu set-up CrAlarm history rel>nrt fec(1jtli�iti ie (print)• Bryan Lundien Signature: ICC# �to \A 6'C - Ls —k License. No.: 485184 �� L'estiil�Cvmpany�NameSery Sta Sys Thune No.: (408) 971-2445 ,Eis�iiys t'btn'patty Address: 680 Quinn Ave., San Jose CA 95112 Date of'I•estimgiSeryicing: 12111!09 r , Tilt k ID Tank IQ* Model: [3 In - yank Gauging Probe. Model: [3 in - Tank Gauging Probe. ❑ ,%nnular Space or Vault sensor. Model: IModel:tj-1:1111%6nip ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump % Trench Sensor (s). Model: E]Piping sump Cl'rench sensor (s). Model: Sensi r (s). ` Model: O fill Sump Sensor W. ;E3;..:4tectutnical Lone Leal,, Detector. Model: E3 Mechanical I.me Leak Detector. Model: p 1�lect')nic Line Leak,l�etedur. In Model: [3U ectronic Linc Leak Delector. Model: 131 anti Overfill 1 l lieh-Level Sensor. Model: ❑ Tank Overfill 1 I ligh-Level Sensor. Model: ❑ (Other ('sgiei ify'equipment type and model in Section L on Page 2). ❑ Other ( specify equipment type and model in Semon I un I':r_c 'Doone (D Tank ID ❑ In - Tank (iaugink Probe. Model: ❑ In - Tank Gauging, Probe. Model: ❑ • ;1nnUI' Space`b V+StYIt Sensor. Modcl: ❑ Annular Space or Vault Sensor. Model: ❑ Pyoipg $V.Mp 1,;l krhtl h Sensor 1 s). Model: ❑ Piping Sump \Trench Sensor (s). Model: - p fitl'Sump Scnsu'r (4; Model: [3 Fill Sump Sensor (s). Madel: ❑ ' NIcchitnical Linc Lcak Detector. Model: [3 Mechanical Line Leak Detector. \9odel: p Glectronic fine Leak Detector. Model: [3 Electronic Line Lxak Detector. Model: . ❑=T.artk OyerftlL r Hip,Level Sensor. Model: E3 'Tank Overfill 't l ligh-Level Sensor. Other ( specify equipment t.\ pc mid model !ckulcL in section 1. on Page ❑ Ocher ( specify equipment type and model in Section G on Page 2). [3 Dispenser ID. Dts nser CohWnttit:nt Sensor (s). ❑':. tx. !vitsdel Dispenser ID• ❑ Dispenser Containment Sensor W. NI:Klel: Cl s,1kcar, Valve W. ❑ ❑ Shear Valve Is1. Dispenser Containment bloat is1 and l'h;un tsl. (] Dispenser Ccontwomcm Floats) and Chain Isl. 'Dis enser In. tj Tenser Containment Sensor (s). Mtxu: Dispenser ❑ ID Dispenser Containment Sens or lsl• Vl�alel: p Shear \/nlve (s) ❑ Shear Valve (s). rj 1)ispenscrContainnocnt float (s) and Chain (s). ❑ Dispenser Containment I loat (,) and Chain tst. !Dispenser In. - Model: Dispenser ❑ ID• Dispenser Containment Sensor (s). Model: ❑ DispenserContainmemt Sensor W. ❑ Shear Valve (s). 0"4hftt Vab'c (s)i - (Jlsgx'I"zt,Con(airmaot Float (s) and Chain (s). ❑ Dispenser Containment I•lout Is) and Chain Is). 11 the the f@cility contains more tanks or dispensers. copt, this Corm. Include inti%mtauun fr ix cery tank and dispenser at the tacobn (. CertifiCation 1 certify that the equipment identified in this document %vas inspected/serviced in accordance with the in guidelines. Attached to this Certification is information (ag. manufactures checklists) necessary to verify that this information is correct and a Plot Plan showin8 the layout of monitoring equipment, for any equipment capable of generating such rellVlifa:lltr>ivf t11 6�tttached a copy of the. ( check rill than npplv): f� tiystetu set-up CrAlarm history rel>nrt fec(1jtli�iti ie (print)• Bryan Lundien Signature: ICC# �to \A 6'C - Ls —k License. No.: 485184 �� L'estiil�Cvmpany�NameSery Sta Sys Thune No.: (408) 971-2445 ,Eis�iiys t'btn'patty Address: 680 Quinn Ave., San Jose CA 95112 Date of'I•estimgiSeryicing: 12111!09 r ,