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MAR-14-2006 38:43 SF` ce Station Systems 408 938 8888 P.03 Monitoring System Equipment Eertification For Use 6,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 he RLepared 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 Facility Name: Loves Country Store Bldg.No-: Site Address: 1553 Colony @ Jacktorle Rd City: Ripon, CA Zip: 95366- Facility Contact Person: Ted Contact Phone No.: (209)599-0740 Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 2121/06 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced; Tank W•(7_6_-Pram Tank ID• ❑ In-Tank Gauging Pmbc. Model: VR 847390-10e ❑ In-Tank Gauging Probe. Model: 7 0 Annular Space or Vault Sensor, Model; VR 7t14390d28 [l Atmular Spacc or Vault Sensor. Modcl. 7 Qg Piping Sump\Trench Sensor(s). Model: VR 7$4380-20e El Piping Sump\Trench Sensor(s). Model: ? Q9 Fill Sump Sensor(s). Model: VR 794.780-208 ❑ Fill Sump Sensor(s). Model: 7 (S Mechanical Line L.cak Detector. Model: FE Petro$TP-Ml_D 171 Mechanical Line Leak Detector. Model: 7 ❑ Electronic Line Leak Detector. :Model; Non- ❑ Electronic Line Leak Detector. Model: 7 ❑ Tank Overfill\High-Level Sensor. Model: Nona ❑ Tank Overfill\Iiigh-Level Sensor. Model: 7 ❑ 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: 7 ❑ In-Tank Ciauging Probe. Model: 7 ❑ Annular Space or Vault Sensor, Model: 7 ❑ Annular Space or Vault Sensor. Model: ? ❑ Piping Sump\Trench Sensor(s). Model: ? [I Piping Sump\Trench Sensor(s). Model: ? ❑ Fill Sump Sensor(s), Model: ? q Fill Sump Sensor(s). Model: ? ❑ Mechanical Line Leak Detector. Model: ? p Mechanical Line Leak Detector. Model: 7 ❑ Flectmnic Line Leak Detector. Model: 7 ❑ Electronic Lino Leak Detector. Model: ? ❑ Tank Overfill\High-Level Sensor. Model: 7 [] Tank Overfill\1-ligh-Level Sensor. Model: 7 p 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: 13.14 Dispenser ID- 1546 M Dispenser Containment Scnsor(s). Model; VR 794380.208Qg Dispenser Containment Sensor(s). Model; VR 794390.208 N Shear Valve(s). Qg Shear Valvc(s). ❑ Dispenser Containment Float(s)and Chain(s). Q Dispenser Containment Float(s)and Chain(s), Dispenser ID: 17-18 Dispenser I m 19-20 M Dispenser Containment Sensor(s). Moder VR 7943811-200 Qg Dispenser Containment Sensor(s), Model: VR 794390.208 a Shear Valve(s). Q9 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 21' _. Dispenser Ib: 22- Q9 Dispenser Containment Sensor(s). Model: VR794350-2oeQC Dispenser Containment Sensor(s). Model: VR 7114299-209 Qg Shear Valve(s). QQ She. Valve(s). ❑ Dispenser Containment 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 arid dispenser m the facility C.CertiflCation- 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.Q.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 aU that appty): d System set-up 0 Alarm history report Technician Name(print): Matt Mulcahy Signature: /,.W'A Mfg.Cert.#.: ICC# 5259466-UT License.No.: 485184 Testing Company Name: Ser.Sta.S s. Phone No.: (408)971-2445 Site Address: 1553 Colony 9,Jacktone Rd Date of Testing/Servicing: 2121/06