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Monitoring System Equipment Certification 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 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: V/R TLS-350 Date of Testing/Servicing: 2127114 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01-Regu Tank ID: 02-Prem ® In-Tank Gauging Probe. Model: VR 847390111 to In-Tank Gauging Probe. Model: VR 847390-111 ® Annular Space or Vault Sensor. Model: VR 794390460 ® Annular Space or Vault Sensor. Model: VR 794390.460 ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 ® Piping Sump\Trench Sensor(s). Model: VR 794380209 ® Fill Sump Sensor(s). Model: VR 794380208 ® Fill Sump Sensor(s). Model: VR 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR Series 8494 ® Electronic Line Leak Detector. Model: VR series 8484 ❑ Tank Overfill\High-Level Sensor. Model: ❑ 7ank Overfill\High-Level Sensor. Model: p 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: Tank lA• ❑ 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: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak 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 Dispenser ID: 03-04 ® Dispenser Containment Sensor(s). Model: VR 794380208 ® Dispenser Containment Sensor(s). Model: VR 794380208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: os-os EDenD: 07-08 11 Dispenser Containment Sensor(s). Model: VR 794390-20a ontainment Sensor(s). Model: VR 794380208 Shear Valve(s). (s). Dispenser Containment Float(s)and Chain(s). ontainment Float(s)and Chain(s). Dispenser ID: 09-10 Dispenser ID• ® 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)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/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; (cbeckfg thatappf}•): ❑ System set-up ❑ 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: 2/27/14