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REGENED JUL t12018 Xh Monitoring System Equipment CertificatiWO MENTAL For Use By All Jurisdictions Within The State of California HEALTH DEPARTMENT 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 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 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 Make/Vlodel of Monitoring System: VR TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Contact Phone No.: (209) 942-2840 Date of Testing/Servicing: 6120/18 Tank ID: 01-Regu Tank ID• 02 Prom ❑ In - Tank Gauging Probe, Model: VR 847390-109 ❑ In - Tank Gauging Probe. Model: VR 847390-109 11 Annular Space or Vault Sensor. Model: VR 794390420 ❑ Annular Space or Vault Sensor. Model: VR 794390420 ® Piping Sump \ Trench Sensor (s). Model: VR 794380-208 IN Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ® Fill Sump Sensor (s). Model: VR 794380208 ® Fill Sump Sensor (s). Model: VR 794380208 ® Mechanical Line Leak Detector. Model: RJ 119-067-8 ® Mechanical Line Leak Detector. Model: FE Petro STP -MLD ❑ 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 111: ❑ 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 \ Trench Sensor (s). 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. Mode]: ❑ 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). Dispenser ID: 01-02 ® Dispenser Containment Sensor (s). Model: VR 794380209 Dispenser ID: 03.04 ® Dispenser Containment Sensor (s). Model: VR 794380208 ® Shear Valve (s). IN Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 05.06 Dispenser ID: ® Dispenser Containment Sensor (s). Model• VR 794380-208 ❑ 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). 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 equipment. For any equipment capable of generating such reports, I have also attached a copy of the; ( cheek all that apply): ® System set-up ® Alarm history report Technician Name (print): Myke Briggs Signature: #" Mfg. Cert.#.: 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 Date of Testing/Servicing: 6/20118