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Monitoring System Equipment Certification For Use,By All Jurisdictions Within The State of California Authw*Cited.Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Regulations This form trust be used to document testing and servicing of monitoring equipment. A selnarate certification or rrpW roust be pfgpa<W for each mort<toring,Ustem control panel by the technician who perforans the work. A copy of this forth trust 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: Raley'te U14 No.: Site Address: 4219 Morada Ln. City: Stockton, CA zip; 95212- Facility Contact Person: Margit Contact Phone No.: "0 195"300- Make/Model of Monitoring System: VIR TLS-360 Date of Testing/Servicing: 7122MO B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to Indicate specific equipment inspected./serviced: Tank EQ,o1-Rsapu __ Tank ID,02-PrOrn Cd In-Tank Gauging probe. Model: vR"7160,106 IN In-Tank Gauging Probe. Model: vat aPNO-1aa IS Annular Space or Vault Sauer, Model: VR?*4WD-ma IS Annular Space or Vault Scow Model- VR a % Piping Sump 1 Trench Sensor(s). Model: VR 7*000-208 IN Piping Sump 1 Trench Sensor(s). Model: Vot?94391-= 11 Fill Sump Sensor(s). Model. VR ranao-mr pt Fill.Sump Sensor(s). Model: Mt 7143ft-M p Mechanics!Lice Leek Dctcciw. Model: none p Mechanical Linc Leak Detect". Model: N,1+ Gj Electronic Line Irak D etwtar_ Morel: VR awl"apes 11 Elerxrtaric Lire Leak Detector. Model: VR awls W4 0 Tank Overfill 1 High-Level Sensor, Model; ewe 0 Tank Overfill 1 Higb-Level Sensor. Model: naw Qt Other(specify equipment type and model in Section E on Page 2). 11 Otho(specify equipment type and model in Section E on Page 2). Tank EQ:--01 Tank Il) M In-Tank Gauging Probe. Mattel. vat 0473art-106 0 In-Tank Gauging Probe. Model: M Annular Space or V Wt Sew" Model: VR 764790Ja3 [] Annular Space or Vault Smspr, Model; Q Piping Sump 1 Trench Sensor(s). Model: vR 764304os _ p Piping Sump!Trench Sensor(s). Model: M Fill Sump Sen"(s), Model: VR 7943W29a 0 Fill Swop Sensor(s). Model: Q Mechanical Line Leak Dcucwar, Model: Now p Mecks"ie d Line leek Detector. Model: Q Electronic Line Leak Detector. Model: VR tracts ata 0 Electronic Line Leak Detector. Model: ( Tank Overfill t High-Lml Sensor. Model: Nen* 0 Tank Overfill\Highdavcl Sensor- Model: M Oder(spccily equipment type and model in Soction E on Page 2). 0 Otber(spoctfy ogwptnw;type and model in Section E on Page 2)- Dispenser ID• 01-02 Dispenser : 0344 M Dirpmer Comtacamaemt Sensor(s). Model: vR TONSO-M I9 Dispense'Cattaimnent Sensor(s). Model: vR 7u380~ua 2 Shear Valve W. IN Shear Valve(s). EI Dispenser Contaimmtmt Float(s)and Chain(s). 0 Dispenser Connaomo nt Flow(s)and Chain(s). Dispenser ID: Otf-06 Dispenser ID; 0148 Iii Dispenser Conaututncni:Season(s). Model: vR?"SOWN QI Dispenser C.ostairnment Senear(a). Model: VR 7660w= a Shear VLIVO(s). Il[ Shear Valve(s). O Dgpatses Cent k—t Float(s)sed Chain(s). d Dispenser Contamment Float(s)and Chain(s). Dispenser IDa 09-10 --- Dispenser ID- 11-12 -- la Dispenser Conuu maent Sensor(s). Model: vR Tesoro-ms pj Disposer Contaitumcrtt Sensor(s), Model: vR tr+saaaos IN Shear Valve(s). IS Shear Valve(s). 0 Dispenser Contairunetrt Float(s)and Chain(s)- p Dispenser Containment Float(s)and Chau(s)- 'lf the facility contains more tanks or dispensers,copy this forth.include informatiop for every tank and disperser at the facility C.Certification- I certify that the equipwemt Identified to this documcat was inapectedlservlctd In accordance with the maadaetmrer's guidelines. Attached to this Certification is inLxaadon(t.g.m sufaetrres'ehecldbts)oecessary to verity that this Iuforinitloe la correct and a Plot Plan showiag the layout of monitoring equtpmest. For any equipment capable of generating such reports,I have also attached a copy of the, (check an"Yat rapp{y). 0 System set-up 12 Alarm history report Technician Name(print!Steve POnMAter Signature: Mfg.Cert,o.; A28780 ICC# 5311581-UT License.No.: +485184 ' Testing Company Name_ Serv.Sta. Phone No.: (408 971-2445 Testing Company Address: 680 Quinn Ave.,San Jose CA 95112 Date of Testing/Servicing: 7122!08