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Monitoring System Equipment Certirication MAY 2 5 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 Code ofpeo�,�,4payINW� w e This form must be used to document testing and servicing of monitoring equipment. A separate certification or re> f mgpared 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: 2132 Mariposa Rd. City: Stockton, CA Gip: 95205 Facility Contact Person: Manager Contact Phone No.: (209)467-3918 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 4/26116 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced: Tank ID:01-Regu Tank ID: 02-Plus ® In-Tank Gauging Probe, Model: VR 947390-107 0 In-Tank Gauging Probe. Model: VR a4A961M 0 Annu ur Space or Vault Sensor. Model: Ronan L 3 ® Annular Space or Vault Sensor. Model: VR 711i&3f 20 ® Piping Sump\Trench Sensor(s). Model: VR 7sue0-20e ® Piping Sump\Trench Sensor(s). Model: VR 7euw2011 ® Fill Sump Sensor(s). Model: VR794380-208 ® Fill Sump Sensor(a). Model: VR 7WIHNNIs ® Mechanical Line Leak Detector. Model: Vleadara LD2000 ® Mechanical Line Leak Detector. Model: R 1104)074 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: a Tank Overfill\Ifigh-Level Sensor. Model: VR 790091-001 ® Tank Overfill\High-Level Sensor. Model M71100914)01 ❑ Other(specify equipment type and model in Section F,on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 03-Prem Tank ID: 04-Diesel 0 In-Tank Gauging Probe. Model: VR x7390-107 ® In-Tank Gauging Probe. Model: VR U739&107 ® Annular Spa"or Vault Sensor. Model: Ronan LS-3 ® Annular Space car Vault Sensor. Model: Ronan Lsa l9 Piping Sump\Trench Sensor(a). Model: VR 794380.200 ® Piping Sump\Trench Sensor(s). Model: yR 794380.208 ® Fill Sump Sensor(s). Model: VR 794390.208 ® Fill Sump Sensor(a). Model: VR 794380.28 ® Mechanical Line Leak Detector. Model: RJ 110-050.5 ® Mechanical Line Leak Detector. Model: vauerlau WEN ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill\High-Level Scum. Model VR 790091401 ® Tank Overfill\High-Level Sensor. Model: VR n00914)01 ❑ Other(specify equipment type and model in Section F on Pago 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 01.02 Dispenser ID: (13-04 ® Dispenser Containment Sensor(a). Model: VR 794380.208 ® Dispenser Containment Sensor(s). Model: VR 794380-278 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(a). ❑ Dispenser Containment Float(s)and Chain(a). Dispenser ID: 05-06 Dispenser ID: 07-08 ® Dispenser Containment Sensor(s). Model VR 79,1390-208 ® Dispenser Containment goDsof(S). Model: VR 7UMB-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(a)and Chain(s). Dispenser ID: 0840 Dispenser ID: 11.12 ® Dispenser Containment Sensor(s). Model: VR na4380-208 10 Dispeaser Containment Sensm(s). Model: VR 7943110a08 ® Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). 4f the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility C.Certification- 1 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 is Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such repotEa,f have also attached a copy of the; (cheekdl thatapply): ❑ Systemset-up ❑ Alarm history report Technician Name(print): Kris Bell Signature:: Mfg.Cert.#.: B33709 ICC# 5297793-UT License.No.: 485184 Testing Company Name: Service Station Systems PhoneNo.: (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose,CA 95112 Date of Testing/Servicing: 4/26116