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Monitoring System Equipment CertificatiodA 2 1 2017 For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California btA, ft0MTAL HEALTH This form must be used to document testing and servicing of monitoring equipment. A scparate certification or reoff@ft llj ENT 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 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 Market Bldg. No -- Site Address: 1409 S. Airport Way City: Stockton, CA Zip: 95206 - Facility Contact Person: Manager Contact Phone No.: 209 942-2840 Make/Model of Monitoring System: VR TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced; Date of Testing/Servicing: 6122117 Tank ID' 01-Regu Tank ID• 02 -Prem ❑ In - Tank Gauging Probe. Model: VR 047390-109 ❑ In - Tank Gauging Probe. Model: VR a47380.100 19 Annular Space or Vault Sensor Model: VR 784390.420 t9 Annular Space or Vault Sensor, Model: VR 794390.420 ® Piping Sump 1 Trench Sensor (s). Model: VR 794380-20e 2 Piping Sump 1 Trench Sensor (s). Model: VR 794380.208 ® Fill Sump Sensor (s). Model; VR 794380-200 N Fill Sump Sensor (s). Model: VR 794380.208 ® Mechanical Line Leak Detector. Model: RJ 110-0873 Mechanical Line Leak Detector. Model: FE Petro STP -MLO ❑ Electronic Line Leak Detector. Model ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill l High -Level Sensor. Model: ❑ Tank Overfill 1 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 IQ: _ __ Tank IQ: ❑ In - Tank Gauging Probe. Model: I] in - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Modcl; ❑ Annular Space or Vault Sensor. Model: [j Piping Sump 1 Trench Sensor (s). Model: [] Piping Sump 1 Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: q Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: [l Electronic Line Leak Detector. Model: p Tank Overfill 1 High -Level Sensor. Model: ❑ Tank Overfill l High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 2). I? 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: VR754380.208 Dispenser Containment Sensor (5). Model: VR 794790-208 ® Shear Valve (s). Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser fl): 05-06 Dispenser ID- ® Dispenser Containment Sensor (s). Model: VR 794380-208 ❑ Dispenser Containment Sensor (s). Model: Igl Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: Dispenser 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). '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 the layout of monitoring eq uipment. For any equipment capable of generating such reports, I have also attached a copy of the; ( check at1 that apply). X System set-up ® Alarm history report Technician Name (print): Kris Bell Signature: Mfg. Cert.#.: 833709 ICC# 5297793 -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: 6122117