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Monitoring System Equipment Ce9i �,Q(Fff IV ED For Use By All Jurisdictions Within The State of California OCT 0 12018 Authority Cited.,Chapter 6.7,Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of Regulationy This form must be used to document testing and servicing of monitoring equipment. A separate celgifiaal;6g-M nespm bb-I EALTH Prepared for each monitoring system control panel by the technician who performs the work. A copy of this�t�fiM to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regu ating UST system within 30 days of test date. A. General Information Facility Name: Manteca Cruisers Bldg,No.: Site Address: 1137W. Lathrop Rd. City: Manteca, CA Zip: 95336- Facility Contact Person: Manager Contact Phone No.: (209) 824-2760 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 8129118 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01-Regu Tank IQ& 02-Prem - a In-Tank Gauging Probe. Model: VR 846390-109 a In-Tank Gauging Probe. Model: VR 846390-109 N Annular Space or Vault Sensor. Model: VR 794390.420 a Annular Space or Vault Sensor. Model: VR 794390420 a Piping Sump\Trench Sensor(s). Model: VR 794300-208 a Piping Sump\Trench Sensor(s). Model: VR 794380-200 X Fill Sump Sensor(s). Model: VR 794380-208 a Fill Sump Sensor(s). Model: VR 794380-206 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR series 8484 a Electronic Line Leak Detector. Model: VR Series 8484 ® Tank Overfill\High-Level Sensor. Model: VR 790091-001 ® Tank Overfill\High-Level Sensor. Model: VR 790091-001 Cc 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 03-Diesel Tank We R In-Tank Gauging Probe. Model: VR 846390-109 ❑ In-Tank Gauging Probe. Model: Cg Annular Space or Vault Sensor. Model: VR 794390420 ❑ Annular Space or Vault Sensor. Model: a Piping Sump\Trench Sensor(s). Model: VR 794360-208 ❑ Piping Sump\Trench Sensor(a). Model: a Fill Sump Sensor(s). Model: VR 794380.208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: a Electronic Line Leak Detector. Model: VR series 6464 ❑ Electronic Line Leak Detector. Model: a Tank Overfill\High-Level Sensor. Model: VR 790091401 p Tank Overfill\High-Level Sensor. Model: I@ 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 U Dispenser Containment Sensor(s). Model: VR 794380-208 a Dispenser Containment Sensor(s). Model: VR 794380-208 N Shear Valve(s). a 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 a Dispenser Containment Sensor(s). Model: VR 794380.208 ® Dispenser Containment Sensor(s). Model: VR 794380-206 a Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 09-10 Dispenser ID: 11-12 N Dispenser Containment Sensor(s). Model: VR 7e438MG8 11 a Dispenser Containment Sensor(s). Model: VR 794380-208 a 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; (check ail thatapply): a System set-up a Alarm history report )3� rs - Technician Name(print): Brian MCPheely Signature: Mfg.Cert.#.: B36745 ICC# 8822062 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; 8129118