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MONITORING SYSTEM CERTIFICATiO For Use By All Jurisdictions Within the State of California :i �k Authority Cited.•-Chapter 6.7, Health acrd Safety Code; Chapter 16, Division 3, Title 23, California 0e oegu atrons This form must be used to document testing and servicing of monitoring equipment, the fiieility.a 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 ownerfoperator must submit a copy of t ' ai kacncy regulating UST systems within 30 days of test date. C"� '�1 'vI I i HEALTH DEPARTMEN-7 A. General Information Facility Name: CRUISERS MANTECA BP29 Bldg.No.: Site Address: 1137 W LATHROP City: MANTECA,CA Zip: Facility Contact Person: MONICA Contact Phone No.: (209) 284-2760 Make/Model of Monitoring System: VEERD ROOT TLS-350 Date of Testing/Servicing: 8/25/2016 B. Inventory of Equipment Tested/Certified Check the appropriate bores to indicatespecific equipment inspected/serviced:: Tank ID: 87 Tank ID: 91 ®In-Tank Gauging Probe, Model: VEEDER ROOT Z In-Tank Gauging Probe. Model: VEEDER ROOT ®Annular Space or Vault Sensor. Model: 304 Z Annular Space or Vault Sensor. Model: 304 Z Piping Sump/Trench Sensor(s). Model: 208 Z Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: 208 Z Fill Sump Sensor(s). Model: 208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: VEEDER ROOT Z Electronic Line teak Detector. Model: VEEDER ROOT ®Tank Overfill/High-Level Sensor. Model: OVERFILL ®Tank Overfill/High-Levcl Sensor. Model: OVERFILL ❑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: DIESEL Tank ID: Z In-Tank Gauging Probe. Model: VEEDER ROOT ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 304 ❑Annular Space or Vault Sensor. Model: ,Z Piping Sump/Trench Sensor(s). Model: 208 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: i ®Electronic Line Leak Detector. Model: VEEDER ROOT ❑Electronic Line leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: FLAPPER ❑Tank Overfill/High-Levci 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: 112 Dispenser ID: 3/4 ®Dispenser Containment Sensor(s), Model: 208 ®Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). — i Dispenser ID: 516 Dispenser ID: 7/8 Z Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9110 Dispenser ID: 11/12 Z Dispenser Containment Sensor(s), Model: 208 ®Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z 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 -1 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 equipment capable of generating such reports,I have also attached a copy of the report; (cheek all that apply): ❑System set-up ❑ Alarm history r port Technician Name(print): GABRIEL VENEGAS Signature: - k Certification No.: B40893 License.No.: Testing Company Name: L.C.SERVICES Phone No.:(559) 444-1730 Testing Company Address: 3887 N VALENTINE FRESNO CA 93722 Date of Testing/Servicing: 8/25/2016 UN-036—1/6 www.unidocs.org Rev.01/17/08