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Monitoring System Equipment Certification NOV 2 3 2o1F 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 O 72(IQy R I�(yp'E This form must be used to document testing and servicing of monitoring equipment. A separate certification or rreeor�' rt�t�i'f 1j� �n e�-,��A grepared for earb monitoring 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 system within 30 days of test date. A. General Information Facility Name: Rancho San Miguel Bldg. No.: Site Address: 610 S. Cherokee Ln. City: Lodi, CA Zip: 95240 - Facility Contact Person Manager Contact Phone No.: (209) 339-8200 Make/Model of Monitoring System: VR TLS -350 Date of Testing/Servicing: 10126/15 B. Inventory of Equipment Tested/Certified -If the facility contains more tanks or dispensers, copy this form. Include information for every pink and dispenser at the facility' C. Certification - I certify that the equipment identified in this document was inspecfed)serviced in accordance with the manufActurer's guidelines. Attached to this Certification is information (e.g. manufactures' 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: (cbect<all Mat apply): ❑ System set-up ❑ Alarmhistory report Technician Name (print): Kris Bell Signature: ./ �� Mfg. Cert.#.: B33709 ICC# 5297793 -UT License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (406) 971.2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 10/26/15 Tank IQ. 01-Regu Tank ID- 02 -Prem ® In - Tank Gauging Probe. Madel VR 1147390109 0 In - Tank Gauging Probe. Model VR 987090-1011 ® Annular Space or Vault Sensor. Model: VR 7901399i20 9 Annular Space or Vault Sensor. Model: VR 79t390u6W ® Piping Sump Trench Sensor (a). Model'. VR 7983/10209 ® Piping Sump\ Trench Sensor (s) Model: VR 7W81s ® Fill Sump Sensor (s). Model: VR 7943110.299 ® Fill Sump Sensor (s). Model: VR 79,13e0-2011, M Mechanical Line Leak Detector. Model: FE Petro STPwWla M Mechanical Line Leak Detector. Model. Rd 11fi-0974 ❑ 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 F, on Page 2). ❑ Other ( specity equipment type and model in Section E on Page 21. Tank IQ, Tank 14= ❑ 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 (a). Model. ❑ Piping Sump\ Trench Sensor (a) 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 k High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 21. ❑ Other ( specify equipment type and model in Section E on Page 2). Dispenser ID: 01-02 Dispenser IQ- 03-" a Dispenser Conuinment Sensor (s). Model: VR 79t 21111 ® Dispenser Containment Sensor (s) Madel, VR 794380.2011 ® Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 06.06 Dispenser ID' M Dispenser Containment Sensor (s) Model: VR 79a3110-2011 ❑ Dispenser Containment Sensor (a). Model. a Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Conuinment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: Dispenser ID* ❑ Dispenser Containment Sensor (s) Model: ❑ Dispenser Containment Sensor (a) Model' ❑ Shear VaWe (s). ❑ Shear Valve (s) ❑ Dispenser Containment Fleur(s) and Chain(1) ❑ Dispenser Containment Float (s)and Chain (s)- -If the facility contains more tanks or dispensers, copy this form. Include information for every pink and dispenser at the facility' C. Certification - I certify that the equipment identified in this document was inspecfed)serviced in accordance with the manufActurer's guidelines. Attached to this Certification is information (e.g. manufactures' 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: (cbect<all Mat apply): ❑ System set-up ❑ Alarmhistory report Technician Name (print): Kris Bell Signature: ./ �� Mfg. Cert.#.: B33709 ICC# 5297793 -UT License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (406) 971.2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 10/26/15