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0 0 RE(;L-wtL) Monitoring System Equipment Certification For Use By All Jurisdictions Within The State of California JAN 0 8 2016 ,6 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 tgDQft44 r 77,1* prepared for each monitoring system control Rang) 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: Darren Contact Phone No.: 209 473.7337 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 12/10/15 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank I1)•01-Regu Tank IQ: 02-Prem ® In-Tank Gauging Probe. Model:___YR 847350-109 N In-Tank Gauging Probe. Model: VR 847390-109 C1 Annular Space or Vault Sensor. Model: VR 79439"20 ® Annular Space or Vault Sensor. Model: VR 794390.420 ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 01 Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: yaporless LD2000 0 Mechanical Line Leak Detector. Model: yaportess LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill\High-Level Sensor. Model: VR790091-001 ® Tank Overfill\High-Level Sensor, Model: VR 790091.001 ❑ 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 ID:03-Dieael Tank IDt ® in-Tank Gauging Probe. Model: VR 946400-001 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794390.420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: RJ 116-098-8 ❑ Mechanical Line leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill\High-Level Sensor. Model: VRM091.001 ❑ Tank Overfill\High-Level Sensor. Model. p Other(specify equipment type and model in Section E on Page 2). ❑ 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: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). IlD Dispenser Containment Float(s)and Chain(s). Dispenser ID• 0646 Dispenser ID; 07-08 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). C§ 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: 11 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). is Dispenser Containment Float(s)and Chain(s). 0 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- t 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,l have also attached a copy of the; (check all that apply).- ❑ System set-up ❑ Alarm hist Technician Name(print), Kris Bell Signature- Mfg.Cert.#.: 833709 ICC# 5297793-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 96112 Date of Testing/Seryicing: 12/10/15