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Monitoring m Equipment er xfcatian Systet 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 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 forth 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: 615114 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: Tank ID•01-Rego Tank I • 02•Prem ❑ In-Tank Gauging Probe. Model: VR 647390.109 Q hi-Tank Gauging Prone. Model; VR 847350-109 ® Annular Space or Vault Sensor. Model' VR 794390420 V Annular Space or Vault Sensor. Model: VR 794390-420 ® Piping Sump 1 Trench Sensor(s). Model: VR 794380.209 0 Piping Sump\Trench Sensor(s). Model: VR 794380-209 Pill Sump Sensor(s). Model: VR 794380.208 9 Fill Sump Sensor(s). Model: VR 784380-209 Mechanical Line Leak Detector. Model: RJ 116.057.6 0 Mechanical Line Leak Detector, Model: FE Petro SrP-MLA ❑ 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 IQ; Tank ID• ❑ in-Tank Gauging Probe. Modcf ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Modcl: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Dill 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 Ovcrfiil\high-level Sensor. Model: ❑ Tank Overfill\High-Lovcl Sensor. Model: ❑ Other(specify equipment type and model in Section fi on I'agc 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 01-02 Dispenser ID: 03-04 _ tt@ Dispenser Containment Sensor(s). Model: YR 7943e0-208 ® Dispenser Containment Sensor(s). Model: VR 794380.208 ® Shear Valve(s). S}:car Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser ContainmeRE d Char. Dispenser ID: 05-06 Dispenser ID: Amon .' '"' ® Dispenser Containment Sensor(s). Model: VR 794380-208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s), I+� . L Y ryO�ty ❑ Dispenser Containment Float(s)and Chain(s). C] Dispenser Containment Float(s)A 0-r (s Dispenser ID: Dispenser IQ* ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Contains ❑ Shear Valve(s). ❑ Shear Valve(s) ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(4YJ h TsMENT "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 Plot Plan showing the layout of monitoring equipment. For any equipment capable ofgenerating such reports,I bave also attached a copy orthe; (check aft thst aWy): ❑ 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: 615114