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MAR-14-2006 08:43 St ce Station Systems 408 938 8888 P.02 Monitoring System Equipment .,ertifieation. For Use BY All Jurisdictions N'ithin The State of'California Authority Cited.- Chapter 6.7, Health and Snfet}'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 mast be prepared for each monitoring system control ane! 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. Genera!Information Facility Name: Loves Country Store Bldg.No.: Site Address: 1553 Colony @ Jacktone Rd City: Ripon, CA zip: 95366- Facility Contact Person: Ted Contact Phone No.: (209)599-0740 Make/Model of Monitoring System: V/R TLS-360 hate of Testing/Servicing: 2121106 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment iuspectedtservieed: Tank ID-01-Diesel Tank ID: 02-01esel ❑ In-Tank Gauging Probe, Modem VR 847380-toe ❑ In-'rank Gauging Probe. Mode!' V11847390-109 Q9 Annular Space or Vault Sensor. Model: VR 794390.420 Qg Annular Space or Vault Sensor. Model: VR 794390420 R9 Piping Sump 1 Trench Sensor(s). Nlodcl: VR 7UM-208 29 Piping Sump\Trench Sensor(s). Model: VR 794380.208 13 Frill Sump Scnsor(s). Model: VR 794380,208 Q9 Fill Sump Sensor(s). Model; VR 784390.208 29 Mechanical Line Leak Detector. Model: FE Petro STP-MLD-o Q9 Mechanical Line Leak Detector. Model: FE Petro STP-MILD-1) n Electronic Line Leak Detector. Model: None Electronic Line Leak Detector. Model- None 0 Tank Overfill\High-Level Sensor. Model: None ❑ Tank Overfill\High-Level Sensor. Model: None ❑ Other(specify equipment type and model in Section F.on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2), Tank JR; Q3-Regu Tank ID,.-134-R®gu Q In-Tank Gauging Probe. NlodCl: VR 847390.109 (.] In-Tank Gauging Probe. Model: VR 847390.1 D9 Z Annular Space or Vault Sensor. Model: VR 794390420 29 Annular Space or Vault Scnsor, Model: VR 794390.420 M Piping Sump\Trench Sensor(s). Model._VR7sasso-toe Piping Sump\Trench Sensor(s). Model: VR7943O-= in Fill Sump Sensor(s). Model: VR 794380-2eeQg Fill Sump Sensor(s). Model: VR 794NO-208 M Mechanical Linc Lcak Octcctor. Model: FE Petro STP-MLD Q2 Mechanical Linc Leak Detector, Model; FF Petro STP-MLD ❑ Electronic Line Leak Detector. Model: None ❑ Electronic Linc Leak Detector. Model: None ❑ Tank Overfill\High-Level Sensor. Model: None ❑ Tank Overfill\I ligh-Level Sensor. Model None ❑ Other(spmifv equipment tvpc and model in Section E on Page 2), Q Other(specify equipment type and model in Section E on Page 2), Dispenser ID: 01-02 _ Dispenser ED, N Dispcnscr Containment Sensor(s), Model' VR 794380,203 Q9 Dispenser(:ontainntent Sensor(s). Model: VR 79438D-208 Q9 Shear Valve(s), Ig Shear Valve(s). Ll Dispenser Containment Float(s)and Chain(s). ❑ Dispcnscr Containment Float(s)and Chain(s). Dispenser ID: 05-06 Dispenser M- 07-08 Q9 Dispenser Containment Scnsor(s). Model: VR 794580.208 2g Dispenser Containment Sensor(s). Model: VR794130-206 Q9 Shcar Valve(s). 99 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). p Dispenser Containment Float(s)and Chain(s). Dispenser ID. 09-10 [DispenserED: 11-12 22 Dispcnscr Containmcnt Sensor(s). Modcl: VR7MBO.208 29 Dispenser Containment Sensor(s). Model; VR794320409 961 Shcar Valvc(s), 29 Shear Valve(s). ❑ Dispcnscr Containmcnt Float(s)and Chain(s). 0 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/aerviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verity 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 p Alarm history report Technician Natne(print): Matt Mulcahy Signature: Mfg,Cert.#,: A' ggj I I ICC# 5259466-UT License,No.: 486184 Testing Company Name: Ser.Sta. Sys. Phone No.: (408)971-2445 Site Address: 1553 Colony @ Jacktone Rd _ Date of Testing/Servicing: 2121106