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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 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 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. City: Stockton, CA Zip: 95219 Facility Contact Person: Darren Contact Phone No.: (209)473-7337 Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 3131/11 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate speeiflc equipment inspected/serviced: Tank ID:01-Re92 F2. k ID'02-Prent a In-Tank Gauging Probe. Model: VR 547390-109 n-Tank Gauging Probe. Model: VR$4'7490-mos ® Annular Space or Vault Sensor. Model: VR 7943NA20 nnular Space or Vault Sensor. Model: VR 744390 420 ® Piping Sump\Trench Sensor(s). Model: VR 794380.205 iping Sump\Trench Sensor(s). Model: VR 7MW208 ❑ Fill Sump Sensor(s). Model: ill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: RJ 1164565 Mechanical Line Leak Detector. Model: Vapaisss LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill\High-Level Sensor. Model: VR 79051.001 ® Tank Overfill\High-Level Sensor, Model: VR 790091401 ❑ 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 @b ® In-Tank Gauging Probe. Model: VR 84736167 ❑ In-Tank Gauging Probe. Model: a Annular Space or Vault Sensor. Model: VR 794390420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Model: VR 794360-208 ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: vapor—Ins LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill\High-Level Sensor, Model: VR 79051.001 Cl 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). Disppenser ID: 01-02 Dispenser ID: 03-04 ❑ 15ispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). M Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). M Dispenser Containment Float(s)and Chain(s). Dispenser Ili 05.06 Dispenser Ila; 07.08 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: 09-10 Dispenser ID: 11.12 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® 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 Inspectediserviced in accordance with the manufacturer's guldeliues. 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 ❑n Alarm history report Technician Name(print):Randy Wilkerson Signature: Mfg.Cert.#.: A32404 ICC# 5258560-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: 3/31111