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Monitoring System Equipment CertificMAdi 2017 F'or Use By All.lurisdictians Within The State of California ENVIRONMENTAL HEALTH ANthority Cited:Chapter 6.7,Health and Sglety Code;Chapter 16,Division 3, 771e 13, California Coda bftYtlf A This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the lank 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)339-6200 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 10/25/16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indiente specific equipment hapecled/serviced: Tank ID:01-Regu Tank ID- 02-Prom ❑ In-Tank Gauging Proba _ Model: Va 847390409 ❑ In-Tank Gauging Probe. Model: VR 947390.109 ® Annular Space or Vault Sensor. Model VR 794390420 ® A antdar Space or Vault Sensor, Model: VR 794390420 0 Piping Sump Trench Sensor(a). Model: VR79438e209 00 Piping Sump\Trench Sensor(a), Model: VR 794380,208 0 Fill Sump Sensor(s). Model: VR 794380-208 ® Fill Sump Sensor(s). Model: VR 7MA10,208 ® Mechanical Line Leak Detect". Madel: FE Ferro STP-MLD ® Mechanical Line Leek Detector. Model: RJ rte-057-5-oe7-s ❑ Electronic line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: Cl 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 @: Tank ID: ❑ in-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Madel: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(a). Model: ❑ Fill Sump Scrst r(a). Model: ❑ Fill Sump Sensor(a). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Elecaonic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\Iligh-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Settle,,E on Page 2). Dispenser ID• 01-02 Dispenser to- 03-04 (9 Dispenser Containment Sensor(s). Model: VR794360-208 ® Dispenser Containment Sensor(s). Model: VR 794080.208 ® Shear Valve(s). 19 Shear Valve(s). ❑ Dispenser Containment Float(a)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-06 Dispenser IDS ® Dispenser Containment Sensor(a), Model: VR 794380.208 Cl Dispenser Contamment Sensm(s), Model: M Shear Valve(a). ❑ Shoar Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID1 ❑ Dispenser Containment Sensor(s). Model:_ 0❑ Disperiser Containment Sensor(a). Model: ❑ Shear VaNis(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(a)and Chain(a). ❑ Dispenser Containment Float(a)and Chain(a)- *If the facility contains more looks 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 till,Cerngcntion is information(e.g.manufactures'checklists)necessary to verify that flus Information is correct and a Plat Plan allowing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached n copy of the, (checAall rhetandri: 0 System set-up ® Alarm histnq report (/ Technician Name(print):Randy Wilkerson Signature: //�L(44 Mfg.Cert.#.: A32404 ICC# 6268660-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 521ho(a