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4MA:1vt MAY 2 5 2016 Monitoring System Equipment Certification �N For Use By All Jurisdictions Within The State of California OMMIRS Authority Cited.Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 23, California Code of Regtdatiow aRVI This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared 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 Zip: 95205 Facility Contact Person: Manager Contact Phone No.: (209)4673918 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 4126116 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment impected/serviced: TanklD' Tank ID' ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. :Model: ❑ Annular Space or Vault Sensor. Madel: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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 nn Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tankln• Tank In: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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). Dispenser ID' 13-14 Dispenser ID: ® Dispenser Containment Sensor(s). Model: VR 794380-20a ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispemer Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: _ __ Dispenser 1D: ❑ Dispenser Coutaioment Sensor(s). Model: ❑ Dispenser Conuumou,ni Sensor(s). Model: ❑ Shear Valve(s). ❑ ShearValve(s). ❑ Dispenser Containment Float(s)and Chain(a). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 1D• Dispenser ID: ❑ Dispenser Contaimaent Sensm(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ ShearValve(s). ❑ Shear Valve(s). ❑ DispenserContainment 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 dispemcr 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 thatappty): ❑ System set-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 Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose, CA 95112 Date of Testing/Servicing: 4126116