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r1 • RECEIVED MonIlt®rIlng System Equipment ertifiention' o f 2015 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 HEALTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared 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: VIR TLS-350 Date of Testing/Servicing: 616113 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01-Requ Tank ID: 02-Prem ❑ In-Tank Gauging Probe. Model: VR 847390-109 ❑ In-Tank Gauging Probe. Model: VR 847390-109 ® Annular Space or Vault Sensor. Model: VR 794390420 ® Annular Space or Vault Sensor. Model: VR 794390420 ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 ® Fill Sump Sensor is). Model: VR 794380-208 ® Fill Sump Sensor(a). Model: VR 794280-208 ® Mechanical Line Leak Detector. Model: RJ 11"56.5 ® Mechanical Line Leak Detector. Model: PE Petro STP-rvtt.o ❑ 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). 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: 01-02 Dispenser ID: 03-04 ® Dispenser Containment Sensor(s). Model: VR 794380-208 ® Dispenser Containment Sensor(s). Model: VR 794338-208 ® 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: ® Dispenser Containment Sensor(s). Model: VR 794380408 ❑ Dispenser Containment Sensor(s), Model: ® Sheer 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 Floats)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 manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this information is correct and a Plat Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy ofthe; (checkall thatapply): ❑ System set-up ❑ Alarm history report Technician Name(print): Kris Bell Signature: Mfg.Cert,#.: B337O9 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 96112 Date of Testing/Servicing: 6/6/13