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MonitorhQ SystemipmenWcio 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. As Karate certification or retiort must be prgpared 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: Unocal Bldg.No.: Site Address: 2701 March Ln.a 1-5 City: Stockton, CA Zip: 94219- Facility Contact Person: Manager Contact Phone No.: (209)473-7337 Make/Model of Monitoring System: V/R TLS-350R Date of Testing/Servicing: 3/18109 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID!01-Regu Tank ID,. 02-Prom IN In-Tank Gauging Probe. Model: VR8473W109 IN In-Tank Gauging Probe. Model: VR$47390,109 13 Annular Space or Vault Sensor. Model: VR Annular Space or Vault Sensor. Model: IN Piping Sump\Trench Sensor(s). Model: VR -208 Piping Sump\Trench Sensor(s). Model: VR794380-208 ❑ Fill Sump Sensor(s). Model: Nate ❑ Fill Sump Sensor(s). Model: None 0 Mechanical Line Leak Detector. Model: FE Petro S7P-181.0 IN Mechanical Lige Leak Detector. Model: Vapoftse L® ❑ Electronic Line Leak Detector. Model: $race ❑ Electronic Line Leak Detector. Model: Rory ❑ Tank Overfill\High-Level Sensor. Model: $raw p Tank Overfill\High-Level Sensor. Model: None ❑ 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• M In-Tank Gauging Probe. Model: yR$47390-tog ❑ In-Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: VR 754390.4 ❑ Annular Space or Vault Sensor. Model: M Piping Sump\Trench Sensor(s). ModelyR T9sstn- ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Nam ❑ Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: !La22dW LD200 p Mechanical Lieu Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: nae p Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor, Model: None p Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). p 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: p Dispenser Containment Sensor(s). Model: None 13 Shear Valve(s). 11 Shear Valve(s). IN Dispenser Containment Float(s)and Chain(s). M Dispenser Containment Float(s)and Chain(s). Dispenser IQ. Dispenser ID- 07-08 ❑ Dispenser Containment Sensor(s). Model: N— ❑ Dispenser Containment Sensor(s). Model: N— M Shear Valve(s). l Shear Valve(s). M Dispenser Containment Float(s)and Chain(s). M Dispenser Containment Float(s)and Chain(s). Dispenser IDe 09-10 Dispenser ID• 1142 ❑ Dispenser Containment Sensor(s). Model: Haw p Dispenser Containment Sensor(s). Model: e M Shear Valve(s). M Shear Valve(s). 13 Dispenser Containment Float(s)and Chain(s). M 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; (check all that apply): ❑ System set-up O Alarm history report Technician Name(print): Bryan Lundien Signature: Mfg.Cert.#.: B36094 ICC# 8001468-U License.No.: 485184 Testing Company Name: Serv.Sta.Sys. Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose CA 95112 Date of Testing/Servicing-_L/18109