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JAN 13 2017 Monitoring System Equipment Certification For•Use By All Jurisdictions Within Vie State of Cal forma ENVIRONMENTAL HEALTH PERMITISERVICES Authority Cited:Chapter 6.7,Health and Sq(ety Code;Chapter 16, Division 3, Tule 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must b: prepared 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 n 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: 10125MS B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01-Reflu Tank TD: 02-Pram ❑ In-Tank Gauging Probe. Model-. VR 947390-109 ❑ In-Tank Gauging Probe. Model: VR 947390-109 ® Annular Space or Vault Sensor. Model: VRT94390420 01 Annular Space or Vault Sensor. Model' VR 743390420 ® Piping Sump%Trench Sensor(a), Model: VR 794390-20e 00 Piping Sump l Trench Sensor(a). Madel: VR 784390.209 ® FIII Sump Sensor(s). Model: VR 794380-2DB ® Fill Sump Sensor(s). Model: VR r943e0208 ® Mechanical Line Leak Detector. , Model: FE Per,.STP-MLD ® Mechanical Line Leak Detector. Madel: RJ 1116-07-5 ❑ 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 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 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 Detacmr. Madel: ❑ Tank Overfill%High-Level Sensor. Model: ❑ Tank Overfill V High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E an Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 01-02 Dispenser ID: 03-04 ® Dispenser Containment Sensor(s). Model- vR 794350-208 0 Dispenser Containment Senor(s). Model: VR 794380.208 ® 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 f% ® Dispenser Containment Sensor(s). Model: V1172000408 [I Dispenser Containment Sensor(a). Model: 00 Shear Valve(s). ❑ Shaar Valve(s). ❑ Dispenser Containment Float(a)and Chain(a). ❑ Dispenser Containment Float(a)and Chain(a). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(a). Model: ❑ Dispenser Containment Sensor(a). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(a)and Chain(a). ❑ Dispenser Containment Float(a)and Chain(a). '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 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 file layout of monitoring equipment. For any equipment capable urgenerating such reports,l have also attached a copy of the; (check all rhst.pply): ® Systemset-up ®/Alarm histor3 report Technician Name(print): Randy Wilkerson Signature: Lbf t Mfg.Cert.#.: A32404 ICC# 6268560-UT License.No.: 485184 _ 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