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MONITORING SYSTEM CERTIFICATION AUG 16 2M 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 RTgulati t:NV11ZONI�IL'gff8L 11LAUrl' This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must 1ha'A�$�el Mik- 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 systems within 30 days of test date. A. General Information Facility Name: United Pacific Bldg.No.: #5447 Site Address: 1469 East Hammer Lane City: Stockton, CA Zip: 95210 Facility Contact Person: Tom M.Robins Contact Phone No.: (310)323-3992 ext.#2012 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 08/02118 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicatespecific equipment inspected/serviced: Tank ID: T-1 91 Tank ID: T-2 89 Z In-Tank Gauging Probe. Model: VR-Mag-1 Z In-Tank Gauging Probe, Model: VR-Mag-Plus Z Annular Space or Vault Sensor. Model: VR-409 Z Annular Space or Vault Sensor. Model: VR-409 Z Piping Sump/Trench Sensor(s). Model: VR-208 Z Piping Sump/Trench Sensor(s). Model: VR-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: VMI LD-2000 Z Mechanical Line Leak Detector. Model: VMI LD-2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: Flapper/VR-Mag-1 Z Tank Overfill/High-Level Sensor. Model: Flapper/VR-Mag-Plus ❑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: T-3 87 Tank ID: T-4 Diesel Z In-Tank Gauging Probe. Model: VR-Mag-1 Z In-Tank Gauging Probe. Model: VR-Mag-Plus Z Annular Space or Vault Sensor. Model: VR-409 Z Annular Space or Vault Sensor. Model: VR-409 Z Piping Sump/Trench Sensor(s). Model: VR-208 Z Piping Sump/Trench Sensor(s). Model: VR-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: VMI LD-2000 Z Mechanical Line Leak Detector. Model: VMI LD-2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: Flapper/VR-Mag-1 Z Tank Overfill/High-Level Sensor. Model: Flapper/VR-Mag-Plus ❑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: #34 Z Dispenser Containment Sensor(s). Model: Beaudreau 406 Z Dispenser Containment Sensor(s). Model: Beaudreau 406 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: #5-6 Dispenser ID: #7-8 Z Dispenser Containment Sensor(s), Model: Beaudreau 406 Z Dispenser Containment Sensor(s). Model: Beaudreau 406 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: #9-10 Dispenser ID: Z Dispenser Containment Sensor(s). Model: VR-001 ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑Shear Valve(s). ❑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 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 Z Alarm history report Technician Name(print): RICHARD THOMAS Signature: Certification No.: B34022 License.No.: 803616 Testing Company Name: CGRS,Inc. Phone No.:916-991-1100 Testing Company Address: 5444 Dry Creek Rd.Sacramento,CA 95838 Date of Testing/Servicing: 08/02/18 Page 1 of 4 UN-036— www.unidocs.org Rev.01/17/08