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APR-17-2009 15:22 Service Station Systems 408 938 8888 P.02 MonitorhQ Systemi ri lci For Use By.911 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 forth must be used to document testing and servicing of monitoring equipmennt. AA mparate certification or retnort must be prepared for each monitoring system gotrol panel by the technician who perforins 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. Genergd Information Facility Name: Unocal Bldg.No.: Site Address: 2701 March Ln.@ 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-35OR Date of Testing/Servicing: 3118/09. B. Inventory of]Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspeeted/serviced: Tank ID-411-ROW Tank IDt 02-Prem IN In-Tank Gauging Probe. Model: VR 6473so-109 QI In-Tank Ganging Probe. Model: VR 847390409 a Annular Space or Vault Sensor. Model: vA IN Annular Space or Vault Sensor. Model: VR 794390429 IX Piping Sump\Trench Sensor(s). Model: VR t8 Piping Sump\Trench Sensor(s). Model: VR p Fill Sump Scnsor(s). Model: Note I] Fill Stoup Sensor(s). Model: None 0 Mechanical Line Leak Wector. Model: FE Pato 57-MLO M Mechanical line Leak Detector. Model: 40A0 ® Electronic Line Leak Detector. Model; Naw ❑ Electronic Line Leak Detector. Model: None -� ❑ Tank Overfill\High-Level Sensor. Model; Naw Q Tank Overfill\High-Level Sensor. Model: Naw I] Other(specify equipment type and model in Section E on Page 2), q Other(specify equipment type and model in Section IS on Page 2). Tank ID: 03-Diesel Tank YD• M In-Tank Gauging Probe. Model: VR 847390.709 p In-Tank Gauging Probe, Model; M Annular Space or Vault Sensor. Model: VR 72439"20 ❑ Annular Space or vault Sensor. Model; M Piping Sump\Trench Sensor(s). Model; VR 794340-208 p Piping Sump\Trench Sensor(s)• Model: Q Fill Sump Sensor(s). Model: Naw p Fill Sump Sensor(s). Model, M Mechanical Line Leak Detector. Model: vapeftese L02NO 113 Mechanical Line Leak Detector. Model: p Electronic Line Leak Detector, Model: None p Electronic Line I cak Detector. Model: p Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model; Q Other(specify equipment type and model in Section E on Page 2). p Other(speedy equipment type and model in Section E on Page 2). Dispenser ID• 01-02 Dispenser IQ; 03-04 E3 Dispenser Containment Sensor(s). Model: None p Dispenser Containment Sensor(s). Model: N— is Shear Valve(s). M Shear Valve(s). it Dispenser Containment Float(s)and Chain(s), M Dispenser Containment Float(s)and Chain(s). Dispenser ID• 06-06 Dispenser ID' 07.09 Q Dispenser Containment Sensor(s). Model: Naw p Dispenser Containment Senstr(s), Model: Naw 12 Shear Valve(s). 19 Shear Valve(s). IN Dispenser Containment Float(s)and Chain(s). 11 Dispenser Containment Float(s)and Chain(s). Dispenser ID• 09-10 Dispenser it 0 Dispenser Containment Sensor(s). Model: Naw p Dispenser Containment Sensor('s). Model: t o IS Shear Valve(s). 13 Shear Valve(s), M Dispenser Containment moat(s)and Chain(s). 15 Dispenser Containment Float(s)and Chain(s). *if the facility contains more tanks or dispensem 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'cheeklistt)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; (ekeek alt that apply): p System set-up 0 Alarm history report Technician Name(print): Bryan Lundien Signature: Mfg.Ceti.#,: B36094 ICC## 8001468-U License.No.: 485184 Testing Company Name: Secy.Sta.Sys. Phone No.: 14081971-2445 Testing Company Address: 680 Quinn Ave.,Satz Jose CA 95112 Date of Testing/Servicing: 3/18/09