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Monitoring yCertification 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 Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control 1anel 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: Manager Contact Phone No.: (209) 835-7608 Make/Model of Monitoring System: V/R TLS -350 Simplicity Date of Testing/Servicing: 1/30/14 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectedlserviced: Tank IQ: 01-Regu Tank ID: 02 -Plus ❑ In - Tank Gauging Probe. Model: VR 847390.107 ❑ In - Tank Gauging Probe. Model: VR 847390.107 M Annular Space or Vault Sensor. Model: VR 7943110-301 Annular Space or Vault Sensor. Model: VR 794380.301 M Piping Sump \ Trench Sensor (s). Model:__IR 794380-208 ® Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ® 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 series $484 Electronic Line Leak Detector. Model: VR Series 8484 ❑ 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 ID• 03 -Prem Tank ID• 04 -Diesel ❑ In - Tank Gauging Probe. Model: VR 947390-107 ❑ In - Tank Gauging Probe. Model: VR 847890-107 Annular Space or Vault Sensor. Model: VR 794380-301 IS Annular Space or Vault Sensor. Model: VR 794380-301 ® Piping Sump \ Trench Sensor (s). Model: VR 794380.208 01 Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ® Fill Sump Sensor (s). Model: VR 794380.200 IN Fill Sump Sensor (s). Model: VR 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR series 8484 11 Electronic Line Leak Detector. Model: VR series 84$4 ❑ 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: Dispenser ID.• ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID• Dispenser ID• p Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). enser IQ: Dispenser IQ, [Disp ❑ Dispenser Containment Sensor (s), Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s). ❑ Shear Valve (s). p 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 all that apply): ❑ System set-up ❑ Alarm history report /j Technician Name (print): Steve Parmenter Signature: ``C<_' Mfg. Cert.#.: A28780 ICC# 5311561 -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: 1/30/14