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RtCENED Monitoring System Equipment CertificatiOWEB 2 4 2016 For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California C p This form must be used to document testing and servicing of monitoring equipment. A separate certification or reoit must beAT��FNT preoared 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.: (209) 835-7608 Make/ModeI of Monitoring System: VR TLS -350 Simplicity Date of Testing/Servicing: 1/27116 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank I 01-Regu Tank ❑ ID: 02 -Plus In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: VR 794380.301 Annular Space or Vault Sensor. Model: VR 794380.301 Piping Sump 1 Trench Sensor (s). Model: VR 794380-208 Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ® Fill Sump Sensor (s). Model: VR 794380-20® Igi Fill Sump Sensor (s). Model: VR 794380-208 p Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR 848480-001 Electronic Line Leak Detector. Model: VR a48aea0ol ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ 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 In! 03 -Prem Tank ID: 04-Die8el p In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: VR 79430-8-301 ® Annular Space or Vault Sensor. Model: VR 784380501 ® Piping Sump \ Trench Sensor (s). Model: VR 784380-208 ® Piping Sump \ Trench Sensor (s). Model: VR7843W208 ® Fill Sump Sensor (s): Model: VR 794380.208 ® Fill Sump Sensor (s). Model: VR 794380-208 ❑ Mechanical Line Leak Detector. Model ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR 849480-001 ® Electronic Line Leak Detector. Model: VR 84840MI ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ 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 10 Dispenser Containment Sensor (s). Model: VR 87499aoo1 ® Dispenser Containment Sensor (s). Model: VR 874890.001 W Shear Valve (s). R Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 0"s Dispenser ID: 07-08 ® 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). p Dispenser Containment Float (s) and Chain (s). Dispenser ID: 08-10 Dispenser ID: 11-12 ® 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). ❑ 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 i iat apft): ❑ System set-up ❑ Alarm history report Technician Name (print): Kris Bell Signature: Mfg. Cert.#.: B33709 FCC# 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: 1127116