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0 * RECENED Monitoring System EquipmentCertifiKati o-fil'`1 2018 For Use By All Jurisdictions Within The State of California Authority Cited:Chapter 67, Health and Safety Code;Chapter 16,Division 3, Title 23, Cali/brnif(R*RW90ffY*1'fAL HEALTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or 16 ENT 12re2ared 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 West March Lane City: Stockton,CA — Zip: 95219 Facility Contact Person: Manager Contact Phone No.: (209)473-7337 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 12/14/17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank I%01-Rego Tank IQ: 02-Prem IM In-Tank Gauging Probe. Model: VR 8473MI09 0 In-Tank Gauging Probe. Model: VR 847390109 N Annular Space or Vault Sensor. Model: VR 794390420 11 Annular Space or Vault Sensor. Model: VR 794390420 a Piping Sump\Trench Sensor(s). Model: VR 794HO-208 Piping Sump\Trench Sensor(s). Model: VR 794380208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Vaportess LD2000 Mechanical Line Leak Detector. Model: Vaporless LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill\High-Level Sensor. Model: VR 790091.001 Tank Overfill\High-Level Sensor. Model: VR790091-001 ❑ 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 IQ, 03-Diesel Tank IQ: N In-Tank Gauging Probe. Model: VR 846400001 [3 In-Tank Gauging Probe. Model: it Annular Space or Vault Sensor. Model: VR 7943MA20 [3 Annular Space or Vault Sensor. Model: C1 Piping Sump\Trench Sensor(s). Model: VR794380-208 ❑ Piping Sump\Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model; RJ 116-050.6 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill\High-Lovel Sensor. Model: VR 790091.001 13 Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Dispenser ID; 01-02 Dispenser ID: 03-04 0 Dispenser Containment Sensor(s). Model:-- [I Dispenser Containment Sensor(s). Model: 9 Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID; t05_06 10 ub Dispenser ID: 07-08 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 01 Shear Valve(s). Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). C1 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 09-10 Dispenser ID,• 11-12 D Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: go Shear Valve(s). Co Shear Valve(s). 0 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 aH that apply): 11 System set-up 0 Alarm history report Technician Name(print): Kris Bell Signature: Mfg.Cert.#.: B33709 ICC# 5297793-UT License.No.: 486184 Testing Company Name: Service Station Systems Phone No.; (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 Date ofTesting/Servicing: 12114/17