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�� EIVED Monitoring System Equipment Certi�a�on For Use By A 11.1urisdictions Within The State of California NOV 2 2 2016 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 ce 'NR( EN HEALTH prepared for each monitoring system control Dane! by the technician who performs the work. A copy of this f6EMiqiT4A Td 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: Manager Contact Phone No.: (209)339-8200 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 10/25116 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01-Re90 Tank IQ* 02-Prem ❑ in-Tank Gauging Probe. Model VR 847390-109 ❑ In-Tank Gauging Probe, Model: VRU7390.m9 ® Annular Space or Vault Sensor. Model VR 794390420 It Annular Space or Vault Sensor. Model: VR 796390420 ® Piping Sump\Trench Sensor(a), Model VR 794369-208 ® Piping Sump l Trench Sensor(a), Model: VR 793396209 ® Fill Sump Sensor(a). Model: VR 794380-208 0 Fill Sump Senior(a), Model: VR 794390-209 ® Mechanical Line Leak Detector. _ Model: FE Peho STP-MLD ® Mechanical Line Leak Detector. Model: R 116 D57-5 ❑ 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). Tank IDI Tank 111, ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Mode(: ❑ Piping Sump Trench Sensor(a). Modell ❑ Piping Sump l Trench Sensor(a), 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(specifyequipment qu pment t ype and model N Section F on_Page_). Dispenser ID: 01-02 Dispenser ID: 03.04 ® Dispenser Containment Sensor(a). Model VR 794390.209 ® Dispenser Containment Sensor(a). Model: VR 794396309 ® Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Finals)and Chain(s). Dispenser ID: 05.00 Dispenser 1D: ® Drspenser Containment Sensor(s). Model: VR 7saaea.2oe ❑ Dispenser Containment Sensor (a). Model: 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: llispenser 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). 6lfthe facility contains more tanks or dispensers,copy this form.Include information for every lank 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 Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached R copy of the; (cherkall thorapply): 11 System set-up ® Alarm hixtoq-report (/ Technician Name(print): Randy Wilkerson Signature: /J hy—k Mfg.Cert.#.: A32404 ICC# 5258560-UT License.No.: 465184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 Date of Testing/Servicing: 10/25/16