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WO-8842 MONITORING SYSTEM CERTIFICATION For Use By°All Jurisdictions Within the State ql'Califbrnia Authoritj7 Cited:Chapter 67,Health and Safety,Code; Chapter 16, Division 3, Title 23, California Code ol'Regulations This form must be used to document testing and servicing of monitoring equipment. A—$e crate certific[tion oa report const be spared for each rnonitoriag_svett m control panel by the technician who perforn-is the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit it copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name:United Pacific 5446 Bldg.No.: Site Address: 1403 Country Club City: Stockton Zip: 95201 Facility Contact Person:Site Manager Contact Phone No.:(209)943-2082 Make/Model of Monitoring System:Feeder-Root TLS-350 Date of Testing/Servicing:1211/2017 B. Inventory of Equipment Tested/Certified Check the a ro Hate boxes to Indicates pecific equipment ins ected1serviced:_ Tank ID: Tank ID: El In-'rank Gauging Probe. Model: El In rank Gauging Probe, Model: [:)Annular Space or Vault Sensor. Model: E]Annular Space or\'-suit Sensor, Nlodel: tank D In-'rank 0 Annular a Gauging r I 0"'r'P r - 'V Space 0 ac +c S-uS. 'er"ren h e Sensor .1, 'llulp 11 1 ne l,iping,Sump rri-ench Scnsor(s)� Model: E]Piping Sunap Model, E]Fill Sump Seasons). Model: Fill Sump Sensor(s), Model: 0 1 Mechanical Line Leak Detector. Model: E]Mechanical Line Leak Detector. Model: E 0 o Leak k D t M' Electronic Line Leak Detector. Model: []Electronic Line Leak Delcetor, Model: M' [3 Tank Overfill I High-Level Sensor. Model: E]Tank Overfill/High-Level Scosor. Model: qui me .at and led 0 _p --7tyl' E]Other[specify equipment type and model in Section E on Page 21. 0 Other!specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: El In-Tank Gauging Probe. Model: E3 In-'rank Gauging Prohc. modeL [3 Annular Space or Vault Sensor, Model: ❑Annular Space or Vault Sensor. Model: E]Piping Sump/Trench Sensons). Model: Piping Slow!Trench Scilsov S). 'model; 0 Fill Sump Scllsor(s). Model: [3 Fill Sump Serlsoroo- Model: [3 Mechanical Line Leak Detector, Model: [3 Mechanical Line Leak Detector. Model: [:] Electronic Line Leak Detector, Model: [3 Elcoronic Line Leak Detector. Model: [3 Tank Overfill"High-Level Sensor, Model: E]Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and niodel in Section E on Page 2), Other(specity equipment type and model in Section E on Page 2). Dispenser ID: 3/4 Dispenser ID. Model: Model: 0 Shear Valve(s). Dispenser Valvem. E]Dispenser Containment Floats)and Chain(s). [:]Dispenser Containment Floaus)and chahus), Dispenser ID: Dispenser ID: ModcL Model ❑Shear Valvc(s)- Shear Valve(s). ❑Dispenser Containment Floatts)and Chain(s). C3 Dispenser Contairuncut Floats)and Chaitt(sl. Dispenser ID: Dispenser ID: ODispenser CotitaiiiiiiciitScitsor(s). Model: Model: E]Shear Vah E]Shear Valveos). [3 Dispenser Containment Float(s)anti Chain(s 1, 0 Dispenser Containment Clujilug). *If the facility contains more tanks or dispensers,copy this forni. Include information for every milk and dispenser at the facility, C. Certification-1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers" 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 report;(check all that app�j): F]System set-up Alarm history report Technician Name(print):Daniel Armour Signature. Alarm report Certification No.: A20281.8125807 License.No.: 498721 =_ Testing Company Name: Armour Petroleum Service&Equitnnc nt Corporation ._ Phone No.:(707)437-6668 Testing CompanyAddress:2400 Cement Hill Rd_R3,Fairfield,CA 94533 Date of,Festing/Servicing: 12/112017 Page I of 3 Rev(2/08)