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11 _Vt JAN I A 2 015 Monitoring System Equipment Certiflcatio'! n� C , 'UNI k, 'or Use Av A ll.hfrisdictions Within The :State of California tkl authority Cited: Chapter 67, Health and Safety Code; Chapter 16, Division 3, Title 23, Cal fornix Code of Regula ti'ons This form must be used to document testing and servicing of monitoring equipment. A separate certification orrel2ort must be grenared for each . control p ,-ch monitoring system 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 USTsystem 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: Manager Contact Phone No.: (209) 473-7337 Make/Model of Monitoring System: VR TLS -350 Date ofTesting/Servicing- 12117/14 B. Inventory of Equipment Tested/Certified -h 1, th- a ...,riate boxes to indicate cn�iflr equipment inspeded/sery iced: *If the facility contains more tanks or dispensers, copy this forni. 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' checklist, ) necessary to verily, that this information Li correct and a Plot Plan showing the layout or monitoring equipment. For any equipment capable of generating such reports. I have also attached a copy of the; check all that apply): Q System set-up 0 Alarm his I tory report Technician Name (print)Kris Bell Signature: Mfg. cert*,: B33709 — icc# 6297793 -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: 12/17/14 Tank i -01R09u Tank I .02 -Prom CC In -Tank Gauging Probe. Model: jR 84_7390-109 Cg In - Tank Gauging Probe, Model: VR 847390-109 0 Annular Space or Vault Sensor. Model: .. y�7943W4�20 . . ......... QU Annular Space or Vault Sensor. Model: VR 704390420 0 Piping Sump \ Trench Sensor (s). Model: VR 794380-208 IS Piping Sump \ Trench Sensor (s), Model- VR 794380-208 [] Fill Sump Sensor (5). Model: [3 Fill Sump Scrisot (s) Model Ig Mechanical Line Leak Detector. Model: Val2iess D2000 Mechanical Line Leah Dctector. Model: Vae2dess 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: VR 79009I-001 0 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 1Q.- 03-D'0$01 Tank I off In - Tank Gauging Probe. ModeL VR $46400-001 Q In - Tank Gauging Probe, Model. 01 Annular Space or Vault Sensor. Model: VR 79430420 ❑ Annular Space or Vault Sensor, Model: 11 Piping Sump \ Trench Sensor (s). Model: VR 794380-200 ❑ Piping Sump \ Trench Sensor (s). Model ❑ Fill Sump Sensor (s). Modcl: 0 Fill Sump Sensor (S), Model: Mechanical Line Leak Detector. Model: RJ 116-068.6 ❑ Mechanical Line Leak Detector. Model, Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: Tank Overfill \ High -Level Sensor. Model: VR 790091-001 E) 'rank Overfill \ High -Level Sensor, Model: 0 Other ( specify equipment type and model in Section E on Page 2). 0 Other ( specify equipment type and model in Section L on Page 2). - — -- - ------ - - - ul ul Dispenser IDI 01-02 Dispenser ID: 03-04 0 Dispenser Conutinment Sensor (s). Model: 0 Dispenser Containment Sensor (s). Model 0 Shear Valve (s), N Shear Valve (5). 0 Dispenser Containment Float (s) and Chain (s). N Dispenser Containment Float (s) and Chain (s), Dispenser ID_L 05-06 Dispenser I - 0T,08 0 Dispenser Containment Sensor (s). Model: (3 Dispenser Containment Sensor (s). Model: Q1 Shear Valve (s), N Shear Valve (s). Dispenser Containment Float (s) and Chain (s), qp Dispenser Containment Float (s) and Chain (s) Dispenser ID 09-10 Dispenser ID, 11-12 Dispe _L11 1z E3 Dispenser Containment Sensor (s). Model: 0 Dispenser Containment Sensor (s). Model: Shear Valve ($). 0 Shear Valve (s). 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 forni. 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' checklist, ) necessary to verily, that this information Li correct and a Plot Plan showing the layout or monitoring equipment. For any equipment capable of generating such reports. I have also attached a copy of the; check all that apply): Q System set-up 0 Alarm his I tory report Technician Name (print)Kris Bell Signature: Mfg. cert*,: B33709 — icc# 6297793 -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: 12/17/14