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Aug, 20, 2015 7:07AM No. 0631 P. 2 MON*RING SYSTEM CERTIFIC 'ION se By AH Jurisdictions 6►ithin the State of Califon Authority Cited.-Chapter 6.7, Health and Safefv Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing oFmonitoring equipment, . lkt, �t..;;e arate certification or report mute prepared for each monitoring vo cootrol panel by the technician Re 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 IST Systems within 30 days of lest date. cii,N r„ F 1 E E 0 AUG 2 O 2015 A. General Information ENVIRONMENTAL Facility Name: CRUISERS Bldg,No ACA�TU rIGDARTAAChIT Site Address: 1137 W LATHROP City: MANTECA CA ` Zip: 95354 .Facility Contact Person: RICK Contact Phone No.: 209 824-2760 Make/Model of Monitoring System: VEEDER ROOT TLS-350 _ Date of Test ing'Servicing: 8/19/2015 B. Inventory of Equipment Tested/Certified Check the Appropriate boxes to Indicatespecific a ui meat ins ected/servicedi: i Tank ID: 87 Tank ID: 91 In-Tank Gauging Probe. Model: VEEDER ROOT ®In-Tank Gauging Probe. Model: VEEDER ROOT Annular Space or Vault Sensor. Model: 420NACUUM El Annular Space or Vault Sensor Model: 420NACUUM ❑Piping Sump/Trench Sensor(s). Model: 2081304 Z Piping Sump/Trench Sensor(s). Model: 2081304 i Pill Sump Scnsor(s). Model 2081304 2 Fill Sump Sensor(s). Model: 2081304 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model Q Electronic Line Leak Detector Model: PLLD M Electronic Line Leak Detector. Model: PLLD ©"yank Overfili/Higli-Lcvcl Sensor. Model' VEEDER ROOT ALARM [J Tank Overfill/High-Level Sensor. Nlodel: VEEDER ROOT ALARM ❑Other(specify equipment type and model in Section F,on Page 2). ❑Other(specify equipment type and model in Section E on Pagc 2) Tank ID; DIESEL, Tank 1D: E In-I-ank Gauging Probe. Model' VEEDER ROOT ❑In-Tank Gauging Probe. Model: H Annular Space or Vault Sensor. Model: 420NACUUM ❑Annular Space or Vault Sensor. Model: _ ®Piping Sump!Trench Sensor(s). Model: 2081304 ❑Piping Sump/Trench Sensor(s). Model' ®Fill Sump Sensor(s). Model: 2081304 ❑Fill Sump Sensor(s). tvlodcl; ❑Mechanical Linc Leak Detector. Model ❑Mechanical Line Leak Detector. Model. 121 Electronic Line Lcak Detector Model: PLLD ; []Electronic Dine beak Detector. Model: ®Wank Overfill/High-Level Sensor. Model: VEEDER ROOT ALARM []Tank Overfill/High-Level Sensor. Model _ 1 ©Other(specify equipment type and model in Section E on Page 2) ❑Other(specify equipment type and model in Section E on Page 2.). I Dispenser ID: 1/2 Dispenser Ill: 314 ❑Dispenser Containment Sensor(s). Model: 2081304 M Dispenser Containment Sensogs). Model 2081304 E Shear Valve(s). &Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Ploat(s)and Chain(s). Dispenser ID: 5/6 Dispenser W. 718 ®Dispenser Containment Sensor(s). Model; 2081304 Dispenser Containment Sensor(s) Model: 2081304 Q Shear Valve(s). $hear Valve(s). ❑Dispenser Containment Flost(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). i Dispenser ID: 9/10 Dispenser ID; 11/12 0 Dispenser Containment Sensor(s). ;yodel: 2081304 Dispenser Containment Serlsor(s). Model: 2081304 M Shear Vaive(s') Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). ©Dispenser Containment Float(s)and Chains). *If the facility contains more tzjnks 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 manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Site-Plot Plan showing the layout of monitoring equipment. For any equt ment capable of generating such reports,I have also attached a copy of the report; (check all that apply): ©System set-up Alarm h' report Technician Name(print): GARY HARRIS Signature: Certification No, B340501 ce .e. N Testing Company Name: L.C.SERVICES Phone No.:(559) 444-1730 Testing Company Address: 3887 N VALENTINE FRESNO CA 93722 Date of Testing/Servicing: 8/19/2015 IJN-036—1/6 www.unidocs.org Rev.01/17!QS