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0 0 RECEIVED Monitoring System Equipment Certli .fication FEB 2 1 2018 For Use 13y 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'W960ENTAL HEALT, This form must be used to document testing and servicing of monitoring equipment. A separate certification or reDA-99MRSERVICES 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:Tracy Blvd Shell & Mini Mart Bldg.No.: Site Address: 3725 N. Tracy Blvd. City: Tracy, CA Zip: 95376 Facility Contact Person: Tanya Contact Phone No.:j229)635-760$ Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 1/25/18 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank 1p:01-Regu Tank IT]: 02-Plus D In-Tank Gauging Probe. Model: n In-Tank Gauging Probe, Model: I& Annular Space or Vault Sensor, Model: VR 794380.301 DU Annular Space or Vault Sensor. Model: VR 794330-301 N Piping Sump\Trench Sensor(s). Model: NR 794380.208 N Piping Sump\Trench Sensor(s). Model: VR 794380-208 N Fill Sump Sensor(s). Model: VR 794380-208 Fill Sump Sensor(s). Model: VR 794380-208 ❑ Mechanical ine Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: VR 848480-001 Electronic Line Leak Detector. Model: VR 848480-001 ❑ Tank Overfill\High-Level Sensor, Model: ❑ 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). Tank ID ° 03-Prem Tank ID 4-Diesel [I In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model; VR 794380-301 Annular Space or Vault Sensor. Model: VR 794380-301 Do Piping Sump\Trench Sensor(s). Model: VR 794380-208 Piping Sump\Trench Sensor(s). Model: VR 794380-208 IN Fill Sump Sensor(s). Model: VR 794380-208 Fill Sump Sensor(s). Model: VR 794580-208 El Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: VR 848480-001 Electronic Line Leak Detector. Model: VR 848430-00I ❑ Tank Overfill\High-Level Sensor. Model: 0 Tank 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 E on Page 2). Dispenser I : 01-02 Dispenser I ° 03-04 VR 874990-001 Model: VR 874990-001 Dispenser pens: Dispenser Containment Sensor(s). D spen 'Containment Sensor(s). Model:-- N Shear Valve(s)- IR Shear Valve(s). Dispenser ",Containment Float(s)and Chain(s), ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID; 05-06 Dispenser ID: 07-08 Dispenser Containment Sensor(s). Model: VR 874990-001 X Dispenser Containment Sensor(s). Model; VR 874990.001 Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser I ; 09-10 Dispenser IT)- 11-12 N Dispenser Containment Sensor(s). Model. VR 874990-001 N Dispenser Containment Sensor(s). Model: VR 874990-001 Shear Valve(s). N 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 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 alt that apply): N System set-up B Alarm history report Technician Name(print): Kris Bell Signature: Mf,,,,,.Cert.#.: B33709 icc# 5297793-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 660 Quinn Ave., San Jose, CA 95112 Date ofTesting/Servicing: 1125/18