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MONITORING SYSTEM CERTIFICATION 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 Regulations This form must be used to document testing and servicing of monitoring equipment. the f,e, �A separate certification or report must be prepared for each monit rine 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. k Oflhi,"Page. A. General Information Facility Name: CRUISERS MANTECA BP29 Bldg.No.: Site Address: 1137 W LATHROP City: MANTECA,CA Zip: Facility Contact Person: MONICA Contact Phone No.: (209) 284-2760 Make/Model of Monitoring System: VEERD ROOT TLS-350 Date of Testing/Servicing: 8/25/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment insected/serviceda: FSAnnular ID: 87 Tank ID: 91 ank Gauging Probe. Model: VEEDER ROOT ®In-Tank Gauging Probe, Model: VEEDER ROOT Space or Vault Sensor. Model: 304 ®Annular Space or Vault Sensor. Model: 304 ng Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: 208 ®Fill Sump Sensor(s). Model: 208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector, Model: VEEDER ROOT ®Electronic Line Leak Detector. Model: VEEDER ROOT ®Tank Overfill/High-Level Sensor. Model: OVERFILL ®Tank Overfill/High-Level Sensor. Model: OVERFILL ❑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: DIESEL Tank ID: ®In-Tank Gauging Probe. Model: VEEDER ROOT ❑In=Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 304 ❑Annular Space or Vault Sensor, Model: Piping Sump/Trench Sensor(s). Model: 208 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: 208 ©Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: VEEDER ROOT ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: FLAPPER ❑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 L•on Page 2). Dispenser ID: 112 Dispenser ID: 314 ®Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chaitt(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ®Dispenser Containment Sensor(s), Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9110 Dispenser ID: 11112 ®Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). ;lf 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 Site--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 r port Technician Name(print): GABRIEL VENEGAS Signature: :. Certification No.: B40893 License.No.: I Testing Company Name: L.C.SERVICES Phone No.:(559) 444-1730 Testing Company Address: 3887 N VALENTINE FRESNO CA 93722 Date of Testing/Servicing: 8/25/2016 LIN-036—1/6 www.unidoes.org Rev.01/17/08