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Monitoring ystem Equipment e tiflc tion�Al I 11111 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 k4@RNTAL HEALTH This form must be used to document testing and servicing of monitoring equipment. A Separate certification or repo rtt=rriusffie i �` i t T 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: Tana Contact Phone No.: (209) 835-7608 Make/Model of Monitoring System: VR TLS -350 Date of Testing/Servicing: 1/25117 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: Tank IQ; 01-Regu Tank ID• 02 -Plus ❑ In - Tank Gauging Probe. Model: ❑ in - Tank Gauging Probe. Model: tj Annular Space or Vault Sensor. Model: VR 794380-301 ® Annular Space or Vault Sensor. Model: VR 794380.301 IN Piping Sump \ Trench Sensor (s). Model: VR 79,4380.208 ® Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ® Fill Sump Sensor (s). Model: VR 79,4380-208 ® Fill Sump Sensor (s). Model: VR 794380-208 la Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector, Model: VR 848480-001 ® Electronic Line Leak Detector. Model: VR 849480401 p 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: ❑ In - Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794380-301 ® Annular Space or Vault Sensor. Model: VR 784380-301 ® Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ® Piping Sump \ Trench Sensor (s). Model: VR 794380-208 all Fill Sump Sensor (s). Model: VR 784380-208 ® Fill Sump Sensor (s). Model: VR 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR848480-001 ® 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). ❑ Other ( specify equipment type and model in Section E on Page 2). Dispenser ID,• 01-02 Dispenser ID: 03-04 ® 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 Dispenser ID• 07-08 Chain (s). Dispenser I - 05-06 N Dispenser Containment Sensor (s). Model: VR 874990-001 1& Dispenser Containment Sensor (s). Modcl: VR 874990.001 ® Shear Valve (s). Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). ID 08 10 Dispenser ID 11-12 FDispense,r Dispenser Containment Sensor (s). Model: VR V49s0 001 ® Dispenser Containment Sensor (s). Model: yrt 874990-001 Shear Valve(s). ® Shear Valve (s). Dispensr 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 al/ that apply): ® System set-up ® 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: 1/25/17