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JIJL-14-2011 10:56 Service Station Systems 406 938 8888 P.O4 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, 'rifle 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A scpa tie certification or rcport.Dlust 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/opctator 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:Safewa 2707 Bldg.No.: Site Address: 8425 N. Pacific Ave, City: Stockton, CA zip: 95207• Facility Contact Person: Manager Contact Phone No.: (209) 472.8600 Make/Model of Monitoring System: V/R TLS-350 Date of Tcuting/Servicing: 6/20111 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/servired: TanklD• Tank IP, ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model:— E3 odes❑ Annular Spam or Vault Swam, Model: ❑ Annul at Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s), Model: ❑ Piping Sump\Trench Scnwr(s). Model: ❑ Fill Sump Sensor(a). Model: ❑ Fit]Sump Sensor(s). Mode(: ❑ Mechanical Line Leak Derecmr. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Modcl: ❑ Electronic Line Leak Detector. Model: Cl Tank Over£11\High-Level Sensor. Mwk1: ❑ Tank Overfill\High-Level Scotian 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), Tank In• Tank ll, ❑ In-Tank Gauging Probe. Model: ❑ in-Tank Gauging Probe, Model: ❑ Annular Spam or Vault Sensor. Model: ❑ Annular Spam or Vault Sensor. Madel: ❑ Piping Sump\Trench Swam(s)- Model: ❑ Piping Sump\Trench Sensor(s)- Model: ❑ Fill Sump Swam(s). Model: ❑ Fill Sump Sensor(s). Madel: ❑ Mechanical Line Leak Detector. Model; ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Linc Leak Detector. Model: ❑ Electronic Linc Least Detector. Model: ❑ Tank Overfill\High-Level Sensor, Model: ❑ Tank Overfill\High•Lovel Swarm. Model: ❑ Other(specify equipment type and model in Section E um Page 2). ❑ Other(specify equipment type and model in Section F,on Page 2). Dispenser III; 13.14 Dispenser ID• 15 tg Dispenser Containment Sensor(s). Model: va 7943e0.2e11 ® Dispenser Containment Sensor(s). Model: va rwaea-spa ® Shear Valve(a). 3 Shear Valve(s). ❑ Dispenser Containment Flow(s)and Chain(a). ❑ Uispmser Containment Flout(s)and Chain(s). Dispenser IQ, Dispenser ID ❑ Disponser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor W. Model: ❑ Shcar Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chitin(s). ❑ Disponscr Containment Float(s)and Chain(s). Dispeager ID• Dispenser ID ❑ Dispenser Containment Sensor(s), Model: ❑ Dispcnecr Containment Senaor(A Model: ❑ Shear Valve(s). ❑ Shcar Valve(s). ❑ Dispenser Comaimnent Float(s)and Chain(a). ❑ Dispenser Containment Float(s)and Chain(u)- ,if the facility contains more ranks or dispensers,copy this form.Include information for every tank and dispenser tit 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.manufacrures'checklists)necessary to verify that this information Is correct and a Plot Plan showing the layout of monitoring equipment, Far any equipment capable of generating such repanq I have also attached a copy of the; (eheck all illarapldy)r ❑ System sct-up ❑ Atamt history report — T Technician Name(print): Bryan Lundien signature.. Mfg.Cert.N.: 836094 ICC# 6001468-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2446 Testing Company Address: 630 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 6120/11