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HECEIVEE Monitoring System Equipment CertificatiOWR 18 2015 For Use lay AIt Jurisdictions Within The State of C'alif'ornia Authority Cited;Chapter 67,Health and Safety Code;Chapter.16, Division 3, Title 23, California CoENWR O MENTAL This form must be used to document testing and servicing of monitoring equipment. A separate certification offzKM RTMENT 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:Gas 4 Less Bldg,No.: Site Address: 3434 Manthey Road City: Stockton, CA Zip: 95206- Facility Contact Person: Manager Contact Phone No.:_(209) 234-7869 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 2/18/15 B. inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: Tank iD 01-Rego hank Ill,02-Prem W In-Tank Gauging Probe. Model: VR 846390-111 ® In-Tank Gauging Probe. Model: VR 846390.111 W Annular Space or Vault Sensor. Model: VR 794390.460 ® Annular Space or Vault Sensor. Model: VR 794390.460 is Piping Sump\Trench Sensor(s). Model: VR 794380.208 ® Piping Sump 1 Trench Sensor(s). Model: VR 784380.208 JE Fill Sump Sensor(s). Model: VR 794380.208 ® Fill Sump Sensor(s). Madel: VR 794380-208 ❑ 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-I..evel Sensor. Model: AIR 790091.001 ® Tank Overfill\High-Level Sensor. Model: VR 780081.001 ❑ Other(spccif}'equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID• 'Tank IQ: ❑ 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: ❑ Fil I Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: ❑ Electronic Line teak 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. 01.02 03-04 P Dispenser ID: M Dispenser Containment Sensor(s). Model, VR 794380.208 11 Dispenser Containment Sensor(s). Model: VR 794380.208 ® Shear Valve(s). ® 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 go Dispenser Containment Sensor(s). Model VR 78438x208 Ig Dispenser Containment Sensor(s). Model: VR 794390.208 ® Shear Valve(s). (g) Shear Valve(s) ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 11)• 09-10 Dispenser IQ— Dispenser Containment Sensor(s). Model: VR 794380.208 _ ❑ Dispenser Containment Sensor(s). Model ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment float(s)anis Chain(s) *11*the facility contains more winks 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/seryiced 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; (cheek a8 thatap#j)r ❑ System set-up D Alarm history rrree�port Technician Name(print): Kris Belt 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'resting/Servicing: 2118115