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M onitoring System Equipment CertificatW 5 Zoos For Use By All Jurisdictions iMthin The Sate of California ^ ""t7 n,+w is - Authority Cited.- Chapter 6.7, Health and SsfetyCo* Chapter 16, Divisor 3, Title 23, California Cocl4ofJ�a�ons"_1 Thisform must be used todocument testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control pard 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 regulati ng UST system within 30 daysof test date. A. General 1 reformation Facility Name Rancho San Miguel Market Bldg. No.: SlteAddress 1409 S. Airport Way City: Stockton, CA Zip: 95206 - Facility Contact Person: Olivia Contact Phone No.: (209) 942-2840 Make/Model ofMonitoring System: VR TLS -350 DsteofTesting/Servicing: 6116116 B. I nventory d Equipment Tested/Certified Check the appropriate bncestoindicataspcificecpApnat InVeCaNsarvimd: Tank I D: 01-Regu Tank I On 02 -Prem ❑ In- Tank Gaging Rabe. Model: vR"nss-nos ❑ In- Tale Gaging Probe Model: "ea?ass-1ss ® Annular $»x a Vett Saw, Model: vR nasam2a ❑ Annular Spare or Vault Semr. Model: VR 794ese420 ® Piping SLnp 1 Trench Sensor (s). Model: VR 7skae0-03e ❑ Rping SLrnp \ Trench Sensor (s). Model: vR 79aaea40e ® FII Shp Sensor(s)Modd: v nwsee-ma ❑ FII Sump Saw (s). Model: VR n4lee-0e ® Mahaucal Line Leak Detector. Model: uu kne-se74 ❑ Mechanical Line Leek Detector. Model: FE Petro stvaano ❑ Be:troic Lire Lie Detector. Model: ❑ ❑ectrcnic Line Leak Detector. Model: ❑ Tank Ovetiill \ High -Lend Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other (suedfy a pinent type and model in Sectim E on Page 2). ❑ Otho ( sn:dfy egnipme t type and modd in Section E on Page 2). TanklD: TanklD- ❑ In - Tank Gaging Robe. Model: ❑ In - Talc Gauging Robe, Model: ❑ Annul a Space a Valent Se err. Model: ❑ Amdar. SpaceorVantSesor. Model: ❑ Rpirig Shp l Trach Sesor(s). Model: ❑ Rpirig amp Trench Semor(s). Model: ❑ FII Sump Sascr(s). Model: ❑ Fill Srnp Sesor(s). Model: ❑ Mschaicd Lire Leak Detector. Model: ❑ Mechanical Lire Leak Detector. Model: ❑ 8etronic Li ne Leak Detector. Mudd: ❑ Bedroric Line Leak Detector. Model: ❑ Tack Overfill\ High -Level Sensor. Model: ❑ Tack Overfill\High-Level Saw. Model: ❑ Other ( specify ecOpme t type and model in Section E on Page 2). ❑ Other ( specify ecOpme t type and modd in Section E on Rge 2). Digiertser IQ, 01.02 DIS 10, 03-04 ® Dispensr Cortarrned Sehsor(s). Model: w7Nm2 ms M Dispense Cartanmant Sensor(s). Model: vR msec -ma ® Smeorvave(s). ® Sipa Vave(s). ❑ Dispenser Contamhert Float (s) and Chan (s). ❑ DispenserCo tanrreA Float (s) and Chan (s). Dispenser ID: 05-06 Diad ID: ® Disperner CordanmaASasor(s). Model: v ?sass -me ❑ Disperse Contarment Srsor(s). Model: 11 Shea Vdve(s). ❑ Shea Vave(s). ❑ Dispenser Cadanmed Floor (s) and Chan (s). ❑ Dispenser Containment Float (s) and Chan (s). Dispenser ID: hsr C ❑ DtspaordjnrmMSensr(s). Model: Dispenser [ImsuanserContarvnan ID: Sasor(s). Model: ❑ SearValve(s). ❑ Shea Vave(s). ❑ Dispenser Cortamsrt Root (s) and Chan (s). ❑ Disperser Cortarvr e t Float (s) ad Chan (s). 'If the faility c o tans nnore tanks ordisperses, copy thsfonn. Include information for every tank and dispenser at thafaility C. Certification- I certify that thsequipment identified in thisdmmtentwasirrspectedrsavikad in acordancewith the manufacturar'sgldslines Attached tothisCartifikatim isindamation(at} manufadvea checklists) necessary toverify that this infamatim is cared and a Plot Plan shoxingthe layart of monitoring ekµdprna* For any equipnerd tapable of ganerating such reports I have also attached a copy of the; ( check all rhstapply). ❑ 9u dam sat -cup ❑ Alarm history mart Technician Name (print): Myke Briggs Signature:/ d n Mfg. Cat.#.: B38235 ICC# 8033115 -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 Dateof Testing/Servicing: 6116/16