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Monitoring System Equipment Certification 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 pancl by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator mast 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: V/R TLS-350 Date of Testing/Servicing: 6114/12 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment.inspected/serviced; Tank I •01-Rego Tank I02-Prem 0 In-Tank Gauging Probe, Model: ❑ In-Tank Gauging Probe. Model: a Annular Space or Vault Sensor. Model: VR 794390-420 ® 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 794380-208 M Fill Sump Sensor(s). Model: VR 794380.208 X Fill Sump Sensor(s). Model: VR 794380-208 ® Mechanical Line Leak I}etector. Model: RJ 116-035-,1 ® Mechanical Line Leak Detector. Model: FE Retro STP-MLD ❑ Electronic Line.Leak Detector. Madel: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill 1 High-Level Sensor. Model: El 'Tank Overfill 1 High-Level Sensor. Model: ❑ other(specify equipment type and model in Section E on rage 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank III• Tank Ift ❑ In-'rank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: [] Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model, ❑ Riping Sump 1 Trench Sensor(s), Model: [] Piping Sump 1 Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: [] Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical!Line Lcak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: ❑ 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). n Other(specify equipment type and model in Section E on Page'_). Dispenser ID 001.02 Dispenser ID. 03.04 Dispenser Containment Sensor(s), Model VR 794380.208 ® Dispenser Containment Sensor(s). Model: VR 194390.346 X Shear Valve(s). 0 Shear Valve(s). 12 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID,,05-06 Dispenser I jo Dispenser Containment Sensor(s). Model: VR 794360.286 ❑ 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 winks or dispensers,copy this form.Include information for every tank and dispenser at the facility C.Certification e I certify that the equipment identified in this document was Inspected/sen iced 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; f check all that apply): [] System set-up ❑ Alarm history report Technician Name(print): Randy Wilkerson Signature, Mfg, Cert.#.: A32404 ICC# 5258560-UT License.No.: 485184 'resting Company Name; Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 6114112