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RECEIVED Monitoring System Equipment Certificatioiov i 6 2017 For Use By All Jurisdictions Within The State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, 71fle 23, Californir� B£R 1gppNT This form must be used to document testing and servicing of monitorin f-T V�rv`1�1VV�Itt AL HEALTH g g g equipment. A separate certification or felidm�nshlt AFL H prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provl3ed 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: Rancho San Miguel Bldg.No.: Site Address: 610 S.Cherokee Ln. City: Lodi, CA Zip: 95240- Facility Contact Person: JOSUS Contact Phone No.: (209) 339-8200 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 10/17/17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate speck equipment inspected/serviced: Tank ID:01-Regu Tank ID- 02-Prem ❑ In-Tank Gauging Probe. Model: V0-647390-109 ❑ In-Tank Gauging Probe. Model: vs847390-109 ® Annular Space or Vault Sensor. Model: VR 79/0-0-420 ® Annular Space or Vault Sensor. Model: VR 794390420 ® Piping Sump\Trench Sensor(a). Model: VR 794380-208 ® Piping Sump\Trench Sensor(a). Model: VR 794380409 ® Fill Sump Sensor(a). Model: VR 794380.208 ® Fill Sump Sensor(s). Model: VR 79/380409 ® Mechanical Line Leak Detector. Model: FE Parra STP46D ® Mechanical Line Leak Detector. Model: RJ 118.0574 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Took 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 Sensor(s). 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: 01-02 Dispenser ID: 0304 ® Dispenser Containment Sensor(s). Model: VR 794380408 ® Dispenser Containment Sensor(s). Model: VR 794380408 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-06 Dispenser ID: ® Dispenser Containment Sensor(a). Model: VR79a3e0-208 ❑ Dispenser Comainment Sensor(s). Model: ® Shar Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containmat Float(s)and Chain(s). ❑ Dispetawr Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(a). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Sheat-Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Flat(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chum(s). 'If the facility corrins 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,I have else attached a ropy of the; (rkeckdt fhatapply): 0 System set-up ® Alarm history report Technician Name(print): Brian McPheely Signature: Mfg.Cert.#.: B36745 ICC# 8394903-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 880 Quinn Ave.,San Jose,CA 95112 Date of Testing/Servicing: 10/17/17