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Monitoring System Equipment Certification AU" For Use By All Jurisdictions Within The State of California r . , __L_ Authority Cited.,Chapter 6.7, Health and Safety Code; Chapter 16,Division 3, Title 23, California Cor vpagulai(bn5- --- This form must be used to document testing and servicing of monitoring equipment. A senarate certification or report[Host 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:Raleys Bldg.No.: Site Address: 4219 Morada Ln. City: Stockton,CA Zip. 95212- Facility Contact Person: Manager Contact Phone No.: (209) 956-9300 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 7120/17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to iadicute specific equipment inspected/serviced: Tank ID:01-Regu Tank ID: 02-Prem ® In-Tank Gauging Probe. Model: VR 0443911-10 ® In-Tank Gauging Probe. Model: 101846390-109 01 Annular Space or Vault Sensor. Model: VR794390303 ® Annular Space or Vault Sensor, Model: VR 794380-303 ® Piping Sump\Trench Sensor(a). Model: VR794380-200 ® Piping Sump 1 Trench Sensor(s). Madel: VR 794380-208 ® Fill Sump Sensor(a). Model: VR 794380-200 (1 Fill Sump Sensor(s). Model: "7943110-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: at Electronic Line Look Detector. Model: VR sones 8,184 ® Electronic Line Leak Detector. Model: vR series 9494 51 Tank Overfill\High-Level Sensor. Model: VR790091401 ® Tank Overfill\High-Level Sensor. Model- VR 790041401 ® Other(specify equipment type and model in Section E on Page 2). ® Other(specify equipment type and model in Section E on Page 2), IQ-Tank ID: 03-Diesel Tank ® In-Tank Gauging Probe. Model: VR 84,6390-toe ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model. VR 7MMOZ03 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Model: VR 7943110-2011 ❑ Piping Sump\Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: VR 794380,208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: IN Electronic Line Leak Detector. Model: VR series,8.434 ❑ Electronic Line Leak Detector. Model: ® Tank Overfill\High-Level Sensor. Model: VR 790091.001 ❑ Tank Overfill\High-Level Sensor. Model: ® Other(specify equipment type and model in Section E on Page 2). D Other(specify equipment type and model in Section E on Page 2). Dispenser IDs, 01-02 Dispenser ID: 03-04 03 Dispenser Containment Sensor(5). Model: VR 784380-208 ® Dispenser Containment Sensor(a), Model: Ina 7941380-208 ® Shear Valve(s). 0 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 ® Dispenser Containment Sensor(s). Model: VR794.7a&I09 Z Dispenser Containment Sensor(s). Model: VR 79438&208 Z Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Flom(a)and Chain(a). ❑ Dispenser Containment Float(a)and Chain(a), Dispenser ID; 09.10 Dispenser ID: 11.12 0 Dispenser Containment Sensor(5). Model: VR 79438&208 ® Dispenser Containment Sensor(a). Model: VR 794380-200 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(a)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 took 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.manufactureschecklists)necessary to verify that this information is correct and a Plot Plan showing the layout of moottoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the; (eherkall that apply): ® System set-up ® Alarmhistorry report Technician Name(print): Myke Briggs Signature: Mfg.Cert.#.: B38235 ICC# 8033115-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: 7/20117