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SYSTEMC I 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 Cod R ag This form must be used to document testing and servicing of monitoring equipment. A separate certification or%"W6 h monitoring system control panel by the technician who performs the work. A copy of this form must be providedIves— v on ,Ftgtor. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name 24 Hrs. Gas & Mart Bldg. No.: Site Address: 1901 S. EI Dorado Street City: Stockton, CA Zip: 95206 Facility Contact Person: Saved Contact Phone No.: (209) 207-1252 Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 08/12/2015 Tank ID: #1 Regular 87 - 9000 Gal Tank ID: #2 Premium 81 - 3000 Gal ® In -Tank Gauging Probe, Model MAG -1 ® In -Tank Gauging Probe. Model: MAG -1 ® Annular Space or Vault Sensor. Model: 794380-420 Z Annular Space or Vault Sensor. Model: 794380-420 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: Vaporless 99LD2000 ® Mechanical Line Leak Detector. Model: FE -PETRO MLLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / I ligh-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: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ 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: 1-2 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats) 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/seryiced 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 apply): ® System set-up ® Alarm history report Technician Name (print): Nik Zagorov Signature: N7ar'C'lf Certification No.: Veeder Root Level 4 # A32784 License. No.: 958763 Testing Company Name: ECO-CHEK Compliance, Inc. Phone No.: (888) 500-CHEK Testing Company Address: P.O. Box 1394, Lafayette, CA 94549 Date of Testing/Servicing: 08/12/2015 Page 1 of 4 Rev (2/08)