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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 ofReguladons This form must be used to document testing and servicing of monitoring equipment A separate certification or repprt must be prep-red 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 F i Contact Phone No.: (209) 366-0703 Make/Model of Monitoring System: VR TLS-360 Date of Testing/Servicing: 6121/17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank In.01-Regu Tank ID: 02-Plue ® In-Tank Gauging Probe. Model: VR U73M1)9 0 In-Tank Gauging Probe. Model: VR W3M!09 ® Annular Space or Vault Sensor. Model: VR 791390.420 0 Annular Space or Vault Sensor. Model: VR 7w3 20 ® Piping Sump Trench Sensor(a). Model: VR794590-20e 0 Piping Sump\Trench Sensor(a). Model: VR791390-208 ® Fill Sump Sensor(s). Model: VR 791380-208 ® Fill Sump Sensor(s). Model: VR7943a0-209 ® Mechanical Line Leak Detector. Model: Vepedeaa LD2000 ® Mechanical Line Leak Detector. Model: Vapedeaa LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: R Tank Overfill\High-Level Sensor. Model VR790091401 ® Tank Overfill\High.Levcl Sensor. Model: VR 790091401 ❑ 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 Tank In: 04-Diesel _ ® In-Tank Gauging Probe. Model: VR 847390-109 ® In-Tank Gauging Probe. Model: VR U799)4)7 ® Annular Space or Vault Sensor. Model: VR 7943eor20 2 Annular Space or Vault Sensor. Model: VR 794390420 ® Piping Sump\Trench Sensor(a). Model: VR794300-208 ® Piping Sump\Trench Sensor(s). Model: VR7N380408 ® Fill Sump Sensor(a). Model: VR 794380-708 ® Fill Sump Sensor(s). Model: VR 794380-208 ® Mechanical Line Leak Detector. Model: Vapodess LDmoo 0 Mechanical tine Leak Detector. Model: Iw those-s ❑ Electronic Line Leak Detector. Model: ❑ Electronic Lim Leak Detector. Model: It Tank Overfill\High-Level Sensor. Model: VR 790091.)0 ❑ 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). Dispenser ID: 01-02 Dispenser ID: 03-04 ® Dispenser Containment Sensor(a). Model: VR79ase0.208 ® Dispenser Containment Sensor(a), Model: VR 794300-208 ® Shear Valve(s). ® Sheer Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser W- 0606 Dispenser ID- 07-0e ® Dispenser Containment Sensor(s). Model: VR794380-200 ® Dispenser Containment Sensor(a). Model: VR 7943804208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID. 09-10 Dispenser ID: 11`12 11 Dispenser Containment Sensor(s) Model. VR7%39a209 ® Dispenser Containment Scnsor(s). Model: VR 794380,208 ® Sheer Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(a)and Chain(a). -If the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility C.Certification- I codify that the equipment identified in this document was inspected/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 any equipment capable of generating such reports,I have also attached a copy of the; (ekeckalf rherapldy): 0 System set-up 0 AlarmAlarnl history report Technician Name(print): Kris Bell Signature: Mfg.Cert.#.: U33709 [CC# 5297793-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 96112 Date of Testing/Servicing: 6121117