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EUS ` UT -_ Z619 MAY , NF IMr,n,PDMF, ��pENTAL _. ..T�!ENT MONITORING SYSTEM CERTIFICATION 1 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 of Regulations 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 farm to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Fast&Easy Morada#60 Bldg.No.: Site Address: 10878 North Hwy 99 City: Stockton Zip: 95212 Facility Contact Person: Asim Contact Phone No.: 707-747-2955, ext. 106 Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing:04/12/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 3000 gal Super Tank ID: 5000 gal Sup-2 2 In-Tank Gauging Probe. Model: 847390-107 ¢ In-Tank Gauging Probe. Model: 847390-107 0 Annular Space or Vault Sensor. Model: 794380-420 V Annular Space or Vault Sensor. Model: 794380-420 0 Piping Sump/Trench Sensor(s). Model: 794380-208 V Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 99-LD2000 p Mechanical Line Leak Detector. Model: 99-LD2000 ❑ Electronic Line Leak Detector. Model: C Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model C Tank Overfill/High-Level Sensor. Model: Other(specify equipment t e and model in Section E on Page 2). C Other(speciequipment type and model in Section E on Page 2). Tank ID: 12000 gal Reg Tank ID: 4000 gal DSI 0 In-Tank Gauging Probe. Model: 847390-107 ¢ In-Tank Gauging Probe, Model 847390-107 Annular Space or Vault Sensor. Model: 794380-420 is Annular Space or Vault Sensor. Model: 794380-420 2 Piping Sump/Trench Sensor(s). Model: 794380-208 p Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 99-LD2000 ¢ Mechanical Line Leak Detector. Model: FX1Dv ❑ Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: 2 Other(specify equipment t e and model in Section E on Pae 2). Other(specify equipment t e and model in Section Eon Pa e 2. Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: L Dispenser Containment Sensor(s). Model: o Shear Valve(s). V. Shear Valve(s). v1 Dispenser Containment Floats and Chain(s). 2 Dispenser Containment Floats and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 Dispenser Containment Sensor(s). Model C Dispenser Containment Sensor(s). Model: ✓' Shear Valve(s). IV Shear Valve(s). v Dispenser Containment Floats and Chain(s). w Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: C Dispenser Containment Sensor(s). Model: Shear Valve(s). i_ Shear Valve(s). Dispenser Containment Floats and Chains i. Dispenser Containment Floats 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 manufacturers' guidelines. Attached to this Certification is information(e.g. manufacturers'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 report;(check all that apply): 2 System set-up ®Alarm history report Technician Name(print):Aaron Perrigo Signature: Veeder Root No.: B47853 License.No.: 804904 Testing Company Name: Confidence UST Services Phone No.: 661-631-3870 Testing Company Address: 16250 Meacham Road,Bakersfield,CA 93314 Date of Testing/Servicing: 04/12/2018 Monitoring System Certification Page 1 of 4 12107 1 2/21/07