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Monitoring System Equipment Pertification 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 most be used to document testing and servicing of monitoring equipment. A separate certification or rU=must be praw4 for each monitoring system control panni by the technician who perforans 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: RaWye Bldg.No.: Site Address: 4219 Morada Ln.@. City: SWckton, CA Zip: 95212- Facility Contact Person: Marge Contact Phone No.: (209)958-9300 Make/Model of Monitoring System: WR TLS-350 Date of Testing/Servicing: 7122108 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate spedfie equipment inspectedfurviced: Tank m•Oi4U9u Tank ID• 02-Prom R In-Tank Gauging Probe. Model: vrtansso-ten IS in-Tank Gwiling Probe. Madel: ht 347 a 120 Qi Ammar Space or Vault Swsor. Model: Vn T4320Jaa 0 Annular Space or vault Senses. Model: VR 71430-m (a Prying Sump\Trench Senor(s)- Model: W7114310-201 0 Piping Sump\Trench Sensor(a). Model: Y117M1a0-0m 13 Fill Sump Sensor(s). Model: Ven 7wm-20a 0i Fill Sump Smear(a). Model: Ver n43w.209 ❑ Moelunical Line Leak Detector. Model: sons ❑ Mechanical Line teak Detector. Model: ift M Electronic Linc Lok Detector. Model: V Vka$essm fel Elechonic Lim leak Defector. Model: Va aro esu ❑ Tank Overfill\High-Level Sensor. Model' eons ❑ Tack Overfill\Higb-level Sensor. Model: mons 19 Other(specify equipment type and model in Section E on Page 2). 13 Othcr(specify equiprnet type and model in Section Eon Page 2). Tank ID• 03-0inh Tank Ili Q In-Tank Gauging Probe, Model: VR 13110-109 ❑ In-Tank Gauging Probe. Madel: Ot Annular Space or Vault Sensor. Model: Ver 79320493 ❑ Annular Space or Vault Senor. Model: • Piping Sump\Trench Sensor(s). Model: VR 7643004m ❑ Prying Swap\Trench Sensor(s). Model: Q Fill Sump Serum(s). Model: va7 208 ❑ Fin Sump Sensor(s). Model: ❑ Mechanical Line leak Detector. Model: Hr. ❑ Mechanical Lina Lank Detector. Model: Q Electronic Line Leak Detector. Model: ver aro sta4 ❑ Electronic Line Lank Detector, Model: ❑ Tank Overfill 1 High-Level Sensor. Model: err s ❑ Tank Overfill k High-t.evel Smarr. Model: 13 Oder(spwity equipment type and model in Section E on Page 2). ❑ Oil=(spec4 equipment type and model m Section E on Page 2). Dispenser ID: 01 02 Dispenser ID: 07,04 CK Dispeasa Contavlmmt Sensor(s). Madel', ver nraa0aca 19 Dispenser Cmpdanimtt Sensor(s). Model: Ver 701"O" a is Sheer Valve(s). Shear Valve(s). ❑ Dispenser Containment Flom(s)and Chain(s). ❑ Dispenser Comaim ant Most(s)and Chain(s). A r ID: 06 06 Dispenser ID- 07-M Dh� p Contammrnt SeOwr(a). Model: va 794300-ma IN Dispenser Camainmmt Sensor(a). Model: Ver»aao.am is Shear Valve(3). a Sheer Valve(s). ❑ Disperser Containment Float(s)and Chain(s). ❑ Dupmser Containment floe(a)and Chain(s). Dispenser ID- 1W-10 Dispenser l% 11-12 ll Dispenser Containment Senear(s). Model: vR 7114No-me M Dispenser Centaimment Sensor(s). Model: Ver 794300.209 M Shear Varve(a). Ot Shear Valve(s). ❑ Dispenser Containment Flom(s)and Chain(s). ❑ Dispenser Containment Flom(s)and Cham(s). 'If the thedity contains more[rats or dispenses,copy this fomninclude irlfonmmioo for every tank and dispenser at the facility C.Certification- D certify that the equipment identified Is this document was taspeefedlservited In sectrdance with the maalhctam's guidelines. Attached to this Certification is information(cg.manufactam,cttaidims)necessary to verify,that this i information 6 correct and a Plot Plan showiag the layout of monitoring eguipmeal. For any equipment capable of 7e0enting such "parr,l have at.atfathed a copy of the; (cheek as th u appty): ❑ System ret-up ❑ Atom history report Technician Name(print)• Steve Pallnenter Sigtutture: �. Mfg.Cert.#.: A28780 ICC# 5311581-UT License.No.: 485184 Testing Company Name- Serv.Sta.Syn. Phone No.: (409)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose CA 95112 Date of TesdWServiomg: 7122208