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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, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification cr 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 owner/operator 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: Diamond Petroleum 550 Bldg,No.: Site Address: 550 W.Valpico Rd. City: Tracy, CA Zip: 95376- Facility Contact Person: Manager Contact Phone No.: (925)000-0000 Make/Model of Monitoring System: VR ILS-350 Date of Testing/Servicing: 1214/12 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 x47390-109 0 In-Tank Gauging Probe, Model: VR 847390-109 Dil Annular Space or Vault Sensor. Model: VR 794380.303 ® Annular Space or Vault Sensor. Model: VR 794380.303 ® Piping Sump\Trench Sensor(s). Model: VR 794380.208 ® Piping Sump\Trench Sensor(s). !Model: VR 794380.208 IR Fill Sump Sensor(s). Model: VR 794380-208 ® Fill Sump Sensor(s). Model: VR 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Lute Leak Detector. '.Model: ® Electronic Late Leak Detector. Model: VR Sorioa 8484 ® Electronic Line Leak Detector. Model: VR dories 8484 ❑ Tank Overfill\High-Level Sensor. Model: ❑ 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). Tank IIS: 03-Diesel Tank ID: ® In-Tank Gauging Probe. Model: VR 847390-109 ❑ In-Tank Gauging Probe. Model: ® annular Space or Vault Sensor. Model: VR 794380303 ❑ Annular Space or Vault Sensor. Model: Z Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ Piping Sump\Trench Sensor(s). Model: N 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 beak Detector. Model: VR Soria*8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment typo and model in Section E on Page 2). Disppenser El)- 01.02 Dispenser W- 03-04 ® Dispenser Containment Sensor(s). Model: VR 794380.208 ® Dispenser Containment Sensor(s). Model: VR 784380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Disgw-n.ser 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 N Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• Q9-10Dispenser D. 11-12 ® Dispenser Contairtment Sensor(s). Model: YR 794390.208 ® Dispenser Containment Sensor(s). Model: VR 794380-208 ® Shear Valve(s). N 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 Plan showing the layout of monitoring equipment For any equipment capable of generating such reports,I have also attached a copy of the; (cheek all that apply); ® System set-up IN Alarm history report Technician Name(print): M ke Briggs Signature: Mfg.Cert.#.: 838235 ICC# 8033115-UT 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: 12/4112