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0 0 RECEIVED MONITORING SYSTEM CERTIFICATION MAR 2 5 2016 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 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report itlltt`ti ` ' monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner'pdrator. 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 FacilityName: VALLEY PACIFIC CHARTER WAY Bldg.No.: Site Address: 1501 W CHARTER WAY City: STOCKTON Zip: 95206 Facility Contact Person: MIKE ELIASON Contact Phone No.: (209)948-9412 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 PLUS Date of Testing/Servicing: 311112016 B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to indicatespecific aqui ment ins ected/serviced: Tank ID: 87 Tank ID: DIESEL ®In-Tank Gauging Probe Model VR MAG PLUS ®In-Tank Gauging Probe. Model VR MAG PLUS ®Annular Space or Vault Sensor. Model VR 420 ®Annular Space or Vault Sensor Model- VR 420 ®Piping Sump/Trench Sensor(s) Model. VR 208 ®Piping Sump/Trench Sensor(s) Model VR 208 ❑Fill Sump Sensor(s) Model. ❑Fill Sump Sensor(s). Model- 0 Mechanical Line Leak Detector. Model. MLD STP ®Mechanical Line Leak Detector Model LD2000 ❑Electronic Line Leak Detector Model ❑Electronic Line leak Detector. Model ®Tank Overfill/High-Level Sensor. Model FLAPPER VALVE ®Tank Overfill/High-Levet Sensor Model FLAPPER VALVE ®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 ❑Fell 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-Levet 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. ❑Dispenser Containment Sensor(s) Model! ®Shear Valve(s) ®Shear Valve(s) ®Dispenser Containment Float(s)and Chain(s) ®Dispenser Containment Float(s)and Chain(s). Dispenser ID- 5/6 Dispenser ID: 6A/7 ❑Dispenser Containment Sensor(s) Model ❑Dispenser Containment Sensor(s). Model. ®Shear Valve(s) ®Shear Valve(s) ®Dispenser Containment Float(s)and Cham(s) ®Dispenser Containment Float(s)and Cham(s). Dispenser ID: 7A Dispenser ID: ❑Dispenser Containment Sensor(s). Model ❑Dispenser Containment Sensor(s). Model. ®Shear Valve(s) ❑Shear Valve(s). ®Dispenser Containment Float(s)and Chain(s) ❑Dispenser Containment Float(s)and Cham(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 Piot 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): RICHARD THOMAS Signature: Certification No.: 5012133701 License.No.: 803705 Testing Company Name: TANK TEK ENVIRONMENTAL CORPORATION Phone No.:(707) 779-4999 Testing Company Address: P.O.BOX 5850,RIVERSIDE,CA 92517-5850 Date of Testing/Servicing: 311112016