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Monitoring System Equipment AertificatioriJ For Use By All Jurisdictions Within The State of California nn 77 2015 Authority Cited: Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 23, California Code ofR�gYIIIIII tilfnS A This form must be used to document testing and servicing of monitoring equipment. A separate certiftcatiorrNW6 h"�ENTAP prepared for each monitoring system control panel by the technician who performs the work. A copy of this fot4ii iXt-beTIrVvided—• 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: 1409S.Airport Way City: Stockton,CA Zip: 95206- Facility Contact Person: Manager Contact Phone No.: (209)942-2840 Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 615114 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: Tank I%01-Regu Tank I% 02-Prem ❑ In-Tank Gauging Probe. Model: VR 847390-109 ❑ In-Tank Gauging Probe. Model: VR 647390-109 ® Annular Space or Vault Sensor. Model: VR 794390420 ® Annular Space or Vault Sensor. Model: VR 79x390-420 ® Piping Sump\Trench Sensor(s). Model: VR 794380.208 ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 ® Fill Sump Sensor(s). Model: VR794380-208 ® Fill Sump Sensor(s). Model: VR794380,206 ® Mechanical Line Leak Detector. Model: Rd 116-057-5 ® Mechanical Line Leak Detector. Model: FE Petro STP4LD ❑ 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. VR7943e0-208 ® Dispenser Containment Sensor(s). Model- VR 794380.208 ® Shear Valve(s). 0 Sheer Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). FDeID: 05-05 Dispenser ID: Containment Sensor(s). Model: VR79aa90-z0e ❑ Dispenser Containment Sensor(s). Model: ve(s). ❑ ShearValve(s). Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser I% ❑ 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 fomr.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 Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the; (rkeekali thatapply): ❑ System set-up ❑ Alarm history report Technician Name(print): Kris Bell Signature: Mfg. Cert.#.: B33709 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: 615/14