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r 0 Monitoring System Equipment Certification For Use By AIt 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 per the work, A copy of this form must be provided to the tank system owner/operator. The owne o us 4,etp is rm to the local agency regulating UST system within 30 days of test date. A. General Information SEP 2 8 2018 Facility Name: Manteca Cruisers Bldg.No.: Site Address: 1137W. Lathrop Rd. ENVIRONMENTAL i-6Wnteca, CA Zip: 95336- Facility Contact Person: Manager DEPARTMENT Contact Phone No.: (209) 824-2760 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 8/29118 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 846390-109 ® In-Tank Gauging Probe. Model: VR 846390.109 0 Annular Space or Vault Sensor. Model: VR 794390-420 11 Annular Space or Vault Sensor. Model: VR 794390.420 ® Piping Sump 1 Trench Sensor(s). Model: VR 794380-208 ® Piping Sump 1 Trench Sensor(s). Model: VR 794380-208 ® Fill Sump Sensor(s). Model: VR 794380-208 ® 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 8484 ® Electronic Line Leak Detector. Model: VR series 8484 ® Tank Overfill\High-Level Sensor. Model: VR 790091wool ® Tank Overfill 1 High-Level Sensor. Model: VR 790091.001 ® 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 ID: ® In--rank Gauging Probe. Model: VR 846390-109 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794390.420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\'French Sensor(s). Model: VR 794380-208 Cl Piping Sump 1 Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: VR 794380.208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR series 8484 ❑ Electronic Line Leak Detector. Model: ® Tank Overfill\High-Level Sensor. Model: VR 790091-001 ❑ 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 794380-208 ® Dispenser Containment Sensor(s). Model: VR 794380-20e ® 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 ® Dispenser Containment Sensor(s). Model: VR 794380-208 ® Dispenser Containment Sensor(s). Model: VR 794380-208 ® Shear Valve(s). ® Shear Valve(s). Cl Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 09-10 Dispenser ID: 11-12 ® Dispenser Containment Sensor(s). Model: VR 794380-208 ® Dispenser Containment Sensor(s). Model: VR 794380-20e I@ 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/serviced 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 Pian 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): ® System set-up ® Alarm history report 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