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0 0 Monitoring System Equipment Certlification For Use By All Jurisdictions Within The State of California Authority Cited:Chapter 6.7, Health andSafety 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 nrenared 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.Traicy Blvd. city: Tracy, CA Zip: 95376 Facility Contact Person: Tanya Contact Phone No.: (209)835-7608 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 IT)- Tank ID: ❑ In-Tank Gauging Probe. Model: [I In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: 0 Tank Overfill\High-Level Sensor. Model: ❑ 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). Tank Tank ID [I In-Tank Gauging Probe. Model: [I In-'rank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: [] Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: [I Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: [] Mechanical Line Leak Detector, Model: 0 Electronic Line Leak Detector. Model: 171 Electronic Line Leak Detector. Model: [] Tank Overfill\High-Level Sensor, Model: [3 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 ID- 13-14 Dispenser ID 15-16 C§ Dispenser Containment Sensor(s). Model: VR 874990-001 Dispenser Containment Sensor(s). Model: VR 874990.001 Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). C] Dispenser Containment Float(s)and Chain(s). Dispenser - Dispenser ID;:-- ❑ Dispenser Containment Sensor(s). Model: E] Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). [] Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: [I Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(S). Model:_ 0 Shear Valve(s). ❑ Shear Valve(s). 0 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; (cheek all that apply): N System set-up 0 Alarm history report Technician Name(print): Kris Bell Signature: Mfg.Cert.#.: B33709 - 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 95112 Date of Testing/Servicing: 1126118