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Monitoring System Equipment P 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 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 lest date. A. General information Facility Name: Rancho San Miguel Market Bldg.No.: Site Address: 1409 S.Aireort Way City: Stockton, CA Zip: 95206- Facility Contact Person: Manager Contact Phone No.: (209) 942-2840 Make/Model of Monitoring System: VlR TLS-350 Date of Testing/Servicing: 616113 S. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/:seryiced: Tank.ID:01-Rego Tank ID: 02-Prem ❑ In-Tank Gauging Probe. Model: VR 947390-109 ❑ In-Tank Ganging.Probe. Model: VR 847390-199 ® Annular Space or Vault Sensor. Model: VR 794390420 ® Annular Space or Vault Sensor. Model: VR 794390420 ® Piping Sump 1 Trench Sensor(s). Model: VR 794380.208 ® Piping Sump 1 Trench Sensor(s). Model: VR 794390-20a Z Fill Sump Sensor(s). Model: VR 79439x•208 ® Fill Sump Sensor(s), Model: VR 794380-208 11 Mechanical Line Leak Detector, Model: RJ its-o5s-5 Mechanical Line Leak Detector. Model: FE Petro STP-MLD ❑ Electronic Line Leak Detector. Model: (] Electronic Line Leak Detector. Model: Q Tank Overfill\High-Level Sensor. Model: Q Tank Overfill 1 High-Level Sensor, Model: Q 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 1 Trench Sensor(s). Model: ❑ Piping Sump 1 Trench Sensor(s). Madel: Q Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detectur. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Q Tank Overfill 1 High-Level Sensor. Model: ❑ Tank Overfill 1 high-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). Q Other(specify equipment type and model in Section F on Page 2), Dispenser ID: 01-02 Dispenser ID: 03-04 ® Dispenser Containment Sensor(s). Model: VR 794380-209 (@ Dispenser Containment Sensor(s). Model: VR 794380-208 ® Shear Valve(s). ® Shcar Valve(s). Dispenser Containment Float(s)and Chain(s). Q Dispenser Containment Float(s)atad Chain(s). FDr ID: 05-06 Dispenser ID: er Containment Sensor(s). Model: VR x94380-208 ❑ Dispenser Containment Sensor(s). Model: alve(s). p Shear Valve(s). er Containment Float(s)and Chain(s). Ll Dispenser Containment Float(s)and Chain(s), EDr ID: Dispenser ID: er Containment Sensor(s). Madel: ❑ Dispenser Containment Sensor(s). Mode]: alve(s). ❑ ShearValve(s). er 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 inspectedlseryiced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verily 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; (check all that apply); ❑ System set-up ❑ Alarm history report Technician Name(print): Kris Bell Signature: `' Mfg.Cert.#,: 633709 ICC# 5297793-UT License,No.: 485184 Testing Company Name: Service Station Systems Phone No.: 408 971-2445 Testing Company Address: 680 Quinn Ave, San Jost;, CA 95112 Date of Testing/Servicing; 616113