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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California A 9' 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. A separate certification or rq1i4Wb�\.j4par°6 foY4,eac�n EALT � monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank syste, g vner/ppera {s : 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 : Valley Pacific Petroleum Bldg . No . : N/A Site Address : 1524 Fresno Ave. City : Stockton, CA Zip : 95206 Facility Contact Person : Mike Eliason Contact Phone No . : (209) 993-8793 Make/Model of Monitoring System : Gilbarco EMC Date of Testing/Servicing : 01/16118 B . Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced : Tank ID : T-1 Diesel Tank ID : Z In-Tank Gauging Probe. Model : VR-Mag -Plus ❑ In-Tank Gauging Probe. Model : Z Annular Space or Vault Sensor. Model : VR420 ❑ Annular Space or Vault Sensor. Model Z Piping Sump / Trench Sensor(s). Model : VR-208 ❑ Piping Sump / Trench Sensor(s). Model : ❑ Fill Sump Sensor(s). Model : ❑ Fill Sump Sensor(s). Model Z Mechanical Line Leak Detector. Model : LD-2000 ❑ Mechanical Line Leak Detector. Model ❑ Electronic Line Leak Detector. Model : ❑ Electronic Line Leak Detector. Model : Z Tank Overfill / High-Level Sensor. Model : OPW Flapper Valve ❑ 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 : #1 Satellite ❑ Dispenser Containment Sensor(s). Model : Gilbarco -011 ❑ Dispenser Containment Sensor(s). Model : Gilbarco -011 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). r er ID : #2 Satellite / #3 Satellite Dispenser ID : #3-4nser Containment Sensor(s). Model : Gilbarco -011 ❑ Dispenser Containment Sensor(s). Model : VR-208 Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) 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 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 apptV) : ® System set-up Z Alarm history report Technician Name (print) : Richard Thomas Signature : 1Z "---� Certification No . : 634022 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 : 01/16118 UN-036 — www. unidoes. org Rev. 01 /17/08