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MONITORING SYSTEM 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-4he 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. A. General Information Facility Name: VALLEY PACIFIC COUNTRY MARKET Site Address: 1524 FRESNO AVENUE City: STOCKTON MAR 2 5 2016 Bldg. No.: m Zip: 95206 Facility Contact Person: MIKE ELIASON Contact Phone No.: (209) 948-9412 Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 311112016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID- DIESEL Tank ID: ® In -Tank Gauging Probe. Model VR MAG 1 ❑ In -Tank Gauging Probe. Model ® Annular Space or Vault Sensor. Model VR 420 ❑ Annular Space or Vault Sensor Model ® Piping Sump /Trench Sensor(s) Model VR 208 ❑ Piping Sump / Trench Sensor(s) Model ❑ Fill Sump Sensors) Model ❑ Fill Sump Sensor(s). Model ® Mechanical Line Leak Detector Model LD2000 ❑ Mechanical Line Leak Detector Model ❑ Electronic Line Leak Detector. Model, ❑ Electronic Line Leak Detector. Model ® Tank Overfill / High -Level Sensor Model- FLAPPER VALVE ❑ 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: Tank ID: ❑ In -Tank Gauging Probe. Model ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor Model ❑ Annular Space or Vault Sensor Model ❑ Piping Sump / Trench Sensor(s). Model ❑ Piping Sump /Trench Sensor(s). Model ❑ Fill Sump Sensors) Model ❑ Fill Sump Sensor(s) Model ❑ Mechanical Line Leak Detector Model ❑ Mechanical Line Leak Detector Model ❑ Electronic Line Leak Detector Model ❑ 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: 112 Dispenser ID: 1 SAT GILBARCO GILBARCO ® Dispenser Containment Sensor(s) Model #595000011 ® Dispenser Containment Sensor(s) Model #595000011 ® Shear Valve(s) ® Shear Valve(s) ❑ Dispenser Containment Float(s) and Cham(s) ❑ Dispenser Containment Floats) and Cham(s) Dispenser ID: 2 SAT / 3 SAT Dispenser ID: 3/4 GILBARCO ® Dispenser Containment Sensor(s). Model: #595000011 ® Dispenser Containment Scnsor(s) Model VR 208 ® Shear Valve(s). ® Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model- ❑ Dispenser Containment Sensor(s) Model, ❑ Shear Valve(s). ❑ 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 ® Alarm history report Technician Name (print): RICHARD THOMAS Signature: G_ z ✓�_s Certification No.: 5012133701 License. No.: 803705 Testing Company Name: TANK TEK ENVIRONMENTAL CORPORATION Phone No.: (707) 779-4999 Testing Company Address: P.O. BOX 5850, RIVERSIDE, CA 92517-5850 Date of Testing/Servicing: 3/11/2016