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A. General Information Facility Name: Site Address: TRACY TRUCK STOP 3940 N. TRACY BLVD Facility Contact Person: DEBBIE Bldg. No.: City: TRACY Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Zip: 95304 4-21-17 Tank ID: 87 L, Appendix VI "`• MONITORING SYSTEM CERTIFICATION�'� ® Annular Space or Vault Sensor. For Use By All Jurisdictions Within the State of California ® Annular Space or Vault Sensor. Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California C_nde,,of.Relgulations ® Piping Sump / Trench Sensor(s). This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for ® Piping Sump / Trench Sensor(s). each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ❑ Fill Sump Sensor(s). 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. ❑ Fill Sump Sensor(s). A. General Information Facility Name: Site Address: TRACY TRUCK STOP 3940 N. TRACY BLVD Facility Contact Person: DEBBIE Bldg. No.: City: TRACY Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Zip: 95304 4-21-17 Tank ID: 87 Tank Size: Tank ID: DIE EAST ® In -Tank Gauging Probe. Tank Size: Model: MAG -1 ® In -Tank Gauging Probe. Model: MAG -1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Paige 2). Tank ID: 91 Tank Size: Tank ID: DIE WEST Tank Size: ® In -Tank Gauging Probe. Model: MAG -I ® In -Tank Gauging Probe. Model: MAG -I ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 3000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 7 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor, Model: FLAPPER ❑ 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: I tO 8 Dispenser ID: SIA to 16 ❑ 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: 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: 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 -1 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, 1 have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): DAVE WINKLER Signature: Certification No.. B34975 License No: ]Q Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2n1 STREET GALT, CA 95632 Date of Testing/Servicing: Monitoring System Certification Page 1 of 4