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MONITORING SYSTEM CERTIFICATT JECEIVE'D . For Use By All Jurisdictions Within the State Of C rnia li f Authority Cited-Chapter 6.7. Health and Safety Code,-Chapter 16,Division 3, TV2023 Cavria CodA#&J&*14 This Than must be used to doe-imem testing and servicing of monitoring equipment. :i ifl r r n^t Must --d tkrr each Monilorin cvrd<ao control panel by the technician who performs the wort A copy of this font must be Pro The owncrjopcVgGT must submit a copy of this f0m to the local agency rcagulating Usr systurns within 30 days often a tEPARTMENT A. General information Facility Name: oll Bldg.No.: Site Address: 1700 E.V02601te AVS' City. Manteca.Ca. zip: 95336 Facility Contact Person: SoRnit Contact Phone No.: {408) 230-8999 Maku/Mudel of Monitoring System: Veeder-Q—t TLS-350 Date ofes ftServicing:MUM4 B. inventory of Equipment TestediCerfficd Check lbe avoroprWe boxes to Indicate specific equipmat iateletifterviced. Tank W: T2;91 Task ID; TI:87 0 In Tank Gouging FFQbc- MOLLOI: 0 hr-Tank lag Probc. 0 Annular Spa=or vault Sensor. Model-,7"390-420 Annular qPaW Or Vault Sew". Model: T9439CAM -- wz- 0 pipkig Sump tTremb SonsoO. Wdcl; ?"M piping Sump/Trench Semi(s). Madel! Model: ❑Fill sump scr5or(s), modol; [I Fill SvnV SenswW. Line Leak Detector. model.. Vfm 99Lm2m Mcchunical Line Lcok Deloctur. Mudd-, �VMtWLD�-2000 Eiccame L=Leak Dcuow Modol: ❑Ezatronic Lim Lark PcWor- Model-. Tank Overfill I fth-1-cvct Scr`50T, Model-. Tank Overfill I a4%-UwI Stlzo`- Mcd'A' Other(spwif�cclaipmrnt"c and model in Section B on page 2). U Other(Specify equipment type and model in E on Pap 2). ❑Tsok][D: Tadk ID: Cl in-Tank Gauging Pmtc. model, 0 in-rack Gauging Pwbe- - Model- Ej Amwj%$paw of vadt Semwj. Model: U Annular Spacc or Vauk ScrrAw. MQ": [3 pioingSump/Trench&613200). M0110L - [3 piping Sump i Tftfidl SK901(s), M04161: 0 Fill Sump,SonswW- Uwcl: - 0 Fill Sump Senor(. Modcl; Mechanical Line Leak Dctect0f- Model. C]Mechanical Line I 48k 171000t9r. M0*1- 13lectronic Line Leak Dmotor. M0601-- (3 gjecuosgr Line Leak Detector. Model- Tank()VCFfljl I pjgh4 4vcl StWer. Mc4d: ❑To*ovaffa I Rio-Level Sensor. Model odel in ScrAion F on Ong 2). ❑Odler(specify equipment type and model in Section B on Par 4 0 CXhct(specify 0q0lPwCot=and in Dispenser w. 3&4 Dispesur ID; Mpemer Col%tWng=q scim(s). Model 7943W204 10 Dispenser Containment Sensor(s). Model: 794380-208 ®Sheat Valvc($)� 9 Show Valve(s). 0 CofijAirjmentT-low�&)and ChalnK 0 Dispersw CorwtwinmonL Float(s)WVJ Chain(s). Dispenser to. Dispenser ID: ZT)i$Mn=CcatatirunentSemn 5. 1 — Eg Dispenser(:ontaimnent SmWO), Model; 724M-NO N Shear Valve(s). shearvalvr(s). =IC, ,I-( C(I ==I to. C' Fj VisporacrCorthtinnicni PI000)end Chti*)- DiWn=C01)(8imcal 110SKS)and chain(s). n Dispenser 10- i " [3 Mpanser Containment Sensor(s). Model'. lAdcl-' D' 0 Shear Valve(s). 0 sbw Vdve(&)- rj Dispenser rA.mtaigmgntrIoaj(s)mid chain(s). 794360-208 C1 Dispenser Containmot Flom-(9)and Chain(s). info nal I this form. Include n ion for evexytank and WP;;Z;at—dw facility. qfthc fjoility contains more uwks of dispensers,Copy this rotm. Do w b t1k it C. CortificAtI0111-I certify that tike equip"wt Idenjifled in this document Was jospertedfaerviceil in accordau e WnufneWrars guWarluel, Attacbed to this Ceffificidiun is informalide *11.rannufacturers, cheCkUSIS) satmary to verify that this ilkfffmatiOla is correct and a pl9t Plan obtrwing the layout of loonitoring eqaipmeat; For any equi meat capable of generating 5SCh reports,J have 4160 attached m copy of the report:(L*exk di then apply): system set-up Alarm history report TecbnicjanNwn40ni1)t)-. Guadalupe Sanchez Signatutg-' — IV Certification No.: 11;30138------- License,No.: 883706 Testing Company Name- Reliable Petroleum Services,Inc Phoue No.: 845-8608 hWserviding;1031=4 Dtft OfTest Testing Company Address: 1193AQMHRare�;eft�sho Rd.Oakdsie, pup I of 4 Rev(2/09) Z*d 89699t960Z wne104ed ejqeijeij 89,Z:ZO V L 6Z BnV