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Monitoring System Equipment Certificatid L 2 4 2015 For Use By A11 Jurisdictions Within The State of California M ENTM9 Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of Regulations,c.rl+ce This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be spared for each 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 Market Bldg.No.: Site Address: 1409 S.Airport Way City: Stockton,CA Zip: 95206- Facility Contact Person: Manager Contact Phone No.: (209)942-2840 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 6125115 B. Inventory of Equipment Tested/Certified Check the appropriate boles to indicate specific equipment Inspected/serviced: Tank ID•01-Regu Tank IQ, 02-Prem ❑ In-Tank Gauging Probe. Model: VRO47390-100 ❑ In-Tank Gauging Probe. Model: VR 84739ata9 to Annular Space or Vault Sensor. Model: 101794390420 ❑ Annular Space or Vault Sensor. Model: VR70a390420 ® Piping Sump\Trench Sensor(s). Model: VR 704300408 ® Piping Sump\Trench Sensor(a). Model: on 79439a208 ® Fill Sump Sensor(s). Model: VR 794380.208 ® Fill Sump Sensor(s). Model: VR 704380.200 ® Mechanical Line Leak Detector. Model: Ri 118.0574 Z Mechanical Line Leak Detector. Model: FE Petro STP-MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill 1 High-Level Sensor. Madel: ❑ 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 IQ- 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(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, Madel: ❑ 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- 01-02 Dispenser ll[)!;-0.3=04 ® Dispenser Containment Sensor(s). Model: VR 704380.208 0 Dispenser Containment Sensor(a). Model: VR 784580-208 0 Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID- 04-06 Dispenser ID- M Dispenser Containment Sensor(a). Model: VR794380-200 ❑ Dispenser Containment Sensor(s). Madel: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser In* FDis,penerID• ❑ Dispenser Containment Sensor(s). Model: ispenser Containment Sensor(a). Model:❑ Shear Valve(s). hear Valve(s). Dispenser Containment Float(s)and Chain(s). ispenser Containment Float(s)and Chain(s). elf the facility contains more tanks or dispensers,copy this farm.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 manuracturer's guidelines. Attached to this Certification is information(e.g.manufactures'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,t have also attached a copy of the; (chrekall Thal apply): System set-up Alarm history report Technician Name(print):Kris Bell Signature:_ Mfg.Cert.#.: 833709 ICC# 5297793-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 Date of Testing/Servicing: 6125115