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r-ECEIVED Monitoring System Equipment Certi icat�Rrt 9 ..ops !'or 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 ofRetn�^at� &TAL ENVICIa t This Form must be used to document testing and servicing of monitoring equipment. A separate certification at,rto*ct,m_ta$tMTK11EN� prepared for each monitoring system control panel by the technician who perforins 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: Raleys Bldg.No.: Site Address: 4219 Morada Ln. City: Stockton, CA Zip: 95212- Facility Contact Person: Dawn Contact Phone No.: (209) 956-9300 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 7/10/18 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: Tank ID:01-Regu Tank ID: o2-Prem 2 In-Tank Gauging Probe. Model: VR 846390-109 ® In-Tank Gauging Probe. Model: yR 846390-1109 2 Annular Space or Vault Sensor, Model: VR 794380-303 ® Annular Space or Vault Sensor. Model: VR 794380-303 2 Piping Sump\Trench Sensor(s). Model: VR 794380-208 2 Piping Sump\Trench Sensor(s). Modcl: VR 794380-208 ® Fill Sump Sensor(s). Model: VR 704380.208 ® Pill Sump Sensor(s). Model VR 794380-20e ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model. ® Electronic Line Leak Detector. Model: VR Series 8484 ® Electronic Line Leak Detector. Model: VR Series 8484 ® Tank Overfill\High-Level Sensor. Model: VR 790091.001 ® Tank Overfill\High-Level Sensor. Model: VR 790091.001 ® 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: 03-01esel _ Tank ID' 2 In-Tank Gauging Probe. Model: VR 846390-109 ❑ In-Tank Gauging Probe. Model: 2 Annular Space or Vault Sensor. Model: VR 794380-303 ❑ Annular Space or Vault Sensor. Model: 2 Piping Sump\Trench Sensor(s). Model: vR 794380-209 ❑ Piping Sump\Trench Sensor(s) Model: 2 Fill Sump Sensor(s). Model: VR 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR series 8484 ❑ Electronic Line Leak Detector. Model: ® Tank Overfill\High-Level Sensor. Model: VR 790091-001 ❑ Tank Overfill 1 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 2 Dispenser Containment Sensor(s). Model: VR 794380.208 2 Dispenser Containment Sensor(s). Model: VR 794380-208 2 Shear Valve(s). 2 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-06 Dispenser ID• 07-08 2 Dispenser Containment Sensor(s). Model: VR 794380-208 2 Dispenser Containment Sensor(s). Model: VR 794380-208 2 Shear Valve(s). 2 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 2 Dispenser Containment Sensor(s). Model: VR 794380.208 2 Dispenser Containment Sensor(s). Model: VR 794380.208 2 Shear Valve(s). 2 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 2 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: 7/10/18