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RECEN' ® Monitoring System Equipment Certification for zo�s�� for Use By All Jurisdictions Within The State of California 1\L HEALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califa,gUV )'40 30 DEPARTMENT This fort must be used to document testing and servicing of monitoring equipment. A separate certification or report must be oreoared 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: Raleys Bldg. No.: Site Address: 4219 Morada Ln. Facility Contact Make/Model of Monitoring System: VR TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate bores to Indicate specifsc equipment iospected/serviced: City: Stockton, CA Zip: 95212 - Contact Phone No.: (209) 956-9300 Date of Testing/Servicing: 7110/18 Tank ID: 01 -Regis Tank ID: 02 -Prem ® In- Tank Gauging Probe. Model: VR 846390409 ® In- Tank Gauging Probe. Model: VR 848390-109 ® Annular Space or Vault Sensor. Model: VR79438G-303 ® Annular Space or Vault Sensor- Model: VR 794390403 ® Piping Sump \ Trench Sensor (s). Madel: VR 71438008 9 Piping Sump \ Trench Sensor (s). Model: VR 784390.08 ® Fill Sump Sensor (a). Model: VR 794380-208 19 Fill Sump Sensor (a), Model: VR 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Madel: VR sense 8484 01 Electronic Line Leak Detector. Model: "sane. a4a4 ® Tank Overfill \ High -Level Sensor. Model: VR 790091.301 ® Tank OVenll \ High -Level Sensor. Model: VR 790091-001 ® Other ( specify equipment type and model in Section E on Page 2). 00 Other ( specify equipment type and model in Section E on Page 2). Tank ID: 03 -Diesel Tank ID• ® In - Tank Gauging Probe. Model: VR 840390-109 ❑ In - Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794380403 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump \ Trench Sensor (s). Model: VR 704390408 ❑ Piping Sump \ Trench Sensor (s). Model: ® Fill Sump Sensor (s). Model: VR 794390-208 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: Ira semis 9684 ❑ Electronic Line Leak Detector. Model: ® Tank Overfill \ High -Level Sensor. Model: VR 790091401 ❑ Tank Over ttlI \ 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 11 Dispenser Canminment Sensor (s). Model: VR 794380-2oe ® Dispenser Containment Sensor (a). Model: VR 7e438o-200 ® Shear Valve (s). ® ShearValve (s). ❑ Dispenser Containment Float (s) and Chain (a). ❑ Dispenser Containment Float (a) and Chain (s). Dispenser ID: 05-06 Dispenser ID: 07-08 ® Dispenser Containment Sensor (9). Model: VR 794380408 ® Dispenser Containment Seasor(s). Model: VR 794390438 ® Shear Valve(s). a SbearVulvc (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 09.10 Dispenser ID: 11-12 ® Dispenser Containment Sensor (a). Model: VR 794383.208 ® Dispenser Containment Sensor (5), Model'. VR 794300-208 ® Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Floats) and Chain (a). ❑ 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 a 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; (cherkall that apply): 0 System set-up 0 Alarm mhhistory yreport Technician Name (print): Kris Bell Signature: i✓ ��(/J"'� Mfg. Cert.#.: B33709 ICCs 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: 7/10118