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Fl�EC E .� Monitoring System Equipment CertificationiN 2 ) 2018 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 jVA"R@.NMENTAL This form must be used to document testing and servicing of monitoring equipment. A separate certification or r p hAPARTMENT krepared 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 7.;p: 95242 Facility Contact Person: Manager Contact Phone No.: (209)366-0703 Make/Model of Monitoring System: VR TLS-050 Date of Testing/Servicing: 6119118 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank 1D:01-Regu Tank 11)- 02-Plus ® In-Tank Gauging Probe, Model: VR 847380-109 ® In-Tank Gauging Probe. Model: VR 847390.109 ® Annular Space or Vault Sensor. Model: VR 784390420 ® Annular Space or Vault Sensor. Model: VR 794380-420 ® Piping Sump\Trench Sensor(s). Model: VR 784380-208 ® Piping Sump 1 Trench Sensor(s). Model: VR 794380.208 ® Fill Sump Sensor(s). Model: VR 794380-208 ® Fill Sump Sensor(s). Model: VR794360-208 ® Mechanical Line Leak Detector. Model: Vaporless LD2000 ® Mechanical Line Leak Detector. Model: Vaporless LD2000 ❑ Electronic Line Leak Detector. Model: I ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: VR 790091.001 ❑ Tank Overfill\High-Level Sensor. Model: VR 790081-001 ❑ 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 ID• 04-Diesel ® In-Tank Gauging Probe. Model: VR 847390.109 ® In-Tank Gauging Probe. Model: VR 847390-107 ® Annular Space or Vault Sensor. Model: VR 794390-420 ® Annular Space or Vault Sensor. Model: VR 794390-420 ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 ® Piping Sump\Trench Sensor(s). Model: VR 794380.206 ® Fill Sump Sensor(s). Model: VR 794380-208 ® Fill Sump Sensor(s). Model: VR 794380-208 ® Mechanical Line Leak Detector. Model: Vaporless LD2000 ® Mechanical Line Leak Detector. Model: Rd 116-068-6 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: VR 790001.001 ❑ 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 19 Dispenser Containment Sensor(s). Model: VR 794390-208 19 Dispenser Containment Sensor(s). Model: VR 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-06Dispenser ID: 07-08 ® Dispenser Containment Sensor(s). Model: VR 794380-208 JE Dispenser Containment Sensor(s). Model: VR 794380-200 3 Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 1D: 09-10 Dispenser ID: 11-12 ® Dispenser Containment Sensor(s). Model: VR 7943150-20e ® Dispenser Containment Sensor(s). Model: VR 794380.208 ® Shear Valve(s). 09 Shear Valve(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 - I certify 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; (check all that apply): ® System set-up ® Alarm history report Technician Name(print): Randy Wilkerson Signature: khY4 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: 6/19118