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1y�-- Monitoring System Equipment CertificatiRA12 9 2016 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 Cod\, This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepareI 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:Mobil/Tesoro Bldg.No.: Site Address: 2500 W. Lodi City: Lodi,CA Zip: 95242 Facility Contact Person: manager Contact Phone No.: (209)366-0703 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 611116 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate spec equipment inspected/serviced: Tank ID•91-Regu Tank ID• 02-Plus ❑ In-Tank Gauging Probe. Model: VR 847390-107 ❑ In-Tank Gauging Probe. Model: VR 847390-107 R Annular Space or Vault Sensor. Model: VR794390420 R Annular Space or Vault Sensor. Model: VR 79439020 R Piping Sump\Trench Sensor(s). Model: VR794380-208 R Piping Sump\Trench Sensor(a). Model: VR 794360-208 R Fill Sump Sensor(s). Model: VR794380-208 R Fill Sump Sensor(s). Model: VR794380-208 ® Mechanical Line Leak Detector. Model: RJ 118A565 R Mechanical Line Leak Detector. Model: RJ 11e-o56s ❑ 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• 03•Prem W�030�4 % o4-Diesel ❑ In-Tank Gauging Probe. Model: VR 847390-107 ank Gauging Probe. Model: VR 64739M07 R Annular Space or Vault Sensor. Model: VR794390420 lar Space or Vault Sower. Model; VR 794390-020 R Piping Sump\Trench Sensor(s). Model: VR 7s43eoaoa g Sump\Trench Sensor(s). Model: VR 794380-208 R Fill Sump Sensor(s). Model: VR 794360-208 ump Sensor(s). Model: VR 79438a2U8 R Mechanical Line Leak Detector. Model: RJ 1164565 hanical Line Leak Detector. Model: RJ 11 e-o585 ❑ Electronic Line Leak Detector. Model: tronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: Overfill\High-Level Sensor. Modcl: ❑ Other(specify equipment type and model in Section E on Page 2). r(specify equipment type and model in Section E on Page 2). Dispenser ID• 01-02 ser ID 003-ea R Dispenser Containment Sensor(a), Model: VR 794380.206 R Dispenser Containment Sensor(a). Model: VR 794360.206 R Shear Valve(s). R Shear Valve(s). ❑ Dispense[Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(a)and Chain(s). F2Dispenser ID- 05.06 Dispenser ID• 07-08 R Dispereer Containment Sensor(a). Model: VR794380.208 R Dispenser Containment Sensor(a). Model: V11794380-20e R ShearValve(s). R Shear Velve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser U)• 0940 Dispenser ID• 11.12 R Dispenser Containment Sensor(5). Model: VR 794360.206 R Dispenser Containment Sensor(9). Model: VR794380.208 M Shear Valve(s). R ShearValve(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- Icertify that the equipment identtaed In this document was lnspected/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 say equipment capable of generating such reports,I have also attached a copy of the; (check all thatapply): ❑ System set-up ❑ /Alarm history report Technician Name(print):Randy Wilkerson Signature: //A Mfg.Cert.#.: A32404 ICC# 5258560-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; 611116