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E E Monitoring System Equipment Certific For Use Av All Jurisdictions Within The State of California VELI Authority Cited: Chapter 6.7, Health and ,Safety Code; Chapter 16, Division 3, Title 23, California Code qfIAttl 2015 This form must be used to document testing and servicing of monitoring equipment. A separate c2rti icati=&1*-&rmm-Lmust be IF prepared for each Monilgril3g sgM control 12—anel by the technician who performs the work. A copy of this *�L4y*--We,.j'rA1 to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating'Iftc"ll 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: 96376 Facility Contact Person: Manager Contact Phone No.: (209) 835-7608 Make/Model of Monitoring System: VR TLS -350 Simplicity Date of Testing/Servicing: 1/29115 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced- Tank IDL01_4R090 Tank IQ-, 02 -Plus [I In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model: Jill Annular Space or Vault Sensor, Model: VR 794380-301 Annular Space or Vault Sensor, Model: VR 794300-301 R Piping Sump \ Trench Sensor (s). Model: VR 794380408 tj Piping Sump \ Trench Sensor (s), Model: VR 794300-208 0 Fill Sump Sensor (s), Model: VR 794380-208 Fill Sump Sensor (s). Model: VR 794380-208 0 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector, Model: VR Series 0484 Electronic [.me Leak Detector. Model: VR Series 8484 0 Tank Overfill \ Flit h -Level Sensor, Model: ❑ Tank Overfill \ fligh-Level Sensor, Model: [3 Other ( specify equipment type and model in Section E on Page 2), ❑ Other (specify equipment type and model in Section F. on Page 2). Tank IQ; -0 -3 -Prom Tank IQ'. 04 -Diesel [3 In - Tank Gauging Probc. Model: (3 fit - Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. ModcL VR 794380-301 W Annular Space or Vault Sensor. Model. VR794380-301 N Piping Sump \ Trench Sensor (s). Model: VR 794380-208 0 Piping Sump \ Trench Sensor (s). Model: VR 794380-208 W Fill Sump Sensor (s). Model: VR 794380-208 0 Fill Sump Sensor (s) Model: VR 794380-208 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: Cc Electronic Line Leak Detector. Model: VR Series 9484 0 Electronic Line Leak Detector. Model: VR Series 8484 C) Tank Overfill \ High -Level Sensor. Model: 0 Tank Overfill \ high -Level Sensor. Model: C) 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 Dispenser [tit 0 Dispenser Containment Sensor (s). Model: 0 Dispenser Containment Sensor (s), Model: Shear Valve (s), [] Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s) 0 Dispenser Containment Float (s) and Chain (s). Dispenser jin. Dispenser I 0 Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: E3 Shear Valve (s). ❑ Shear Valve (s), [] Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser IQ: Dispenser 11), [3 I)ispetiserContainment Sensor (s). Model: 0 Dispenser Containment Sensor (s), Model; (3 Shear Valve (s). 0 I Shear Valve (s). j L3 Containment Float (s) and Chain (s). Dispenser Cont, 0 Dispenser Containment Float (s) and Chain (s). •If the facility contains more tanks or dispensers, cop), 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 I,; 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 or generating such reports, I have also attached a copy of the; (check all that apply): 0 System set-up 0 Alarm history report Technician Name (print): Israel Santillan Signature. Mfg. Cert,#.: B33310 — icc# 8057571 -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: 1/29/15