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S y, MONITORING SYSTEM CERTIFICATI 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 at o 4 18 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be re ared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provide tMEMAp . LTH The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. DEPARTMENT A. General Information Facility Name: Valley Pacific Petroleum Site Address: 1501 West Charter Way City: Facility Contact Person: Mike Eliason Make/Model of Monitoring System: Veeder Root TLS -350 Plus B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Bldg. No.: N/A Stockton, CA Zip: 95206 Contact Phone No.: (209) 993-8793 Date of Testing/Servicing: 01/17/18 Tank ID: T-1 87 Tank ID: T-2 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: ® Mechanical Line Leak Detector. Model: MLD -STP ® Mechanical Line Leak Detector. Model: LD -2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: OPW Flapper Valve ® Tank Overfill / High -Level Sensor. Model: OPW Flapper Valve ElOther (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: N/A ❑ Dispenser Containment Sensor(s). Model: N/A ® 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: #7-8 ❑ Dispenser Containment Sensor(s). Model: N/A ❑ Dispenser Containment Sensor(s). Model: N/A ® Shear Valve(s). ®Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: #7 Satellite Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: N/A ❑ 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). *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 ® 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: 01/17/18 UN -036 — www.unidocs.org Rev. 01/17/08