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From: 09/28/2017 13:28 #843 P_002/008 MONITORING SYSTEM CERTIFICATION cD For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Aeahh and Safely Code;Chapter 16,Division 3, Title 23,California Codi;a_R ulattons This form must be used to document testing and servicing of monitoring equipment. A separate certification or report most 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/opemmr. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 dajrsbf test date. .'TH ! A. General Information r! i Facility Name: 953 Tracy Fedex Ground Bldg,No.: Site Address: 5655 Hood Way City: Tracy Zip: 95377 t Facility Contact Person: Jose Jimenez Contact Phone No.: (209) 830-5254 � Make/Model of Monitoring System:Veeder Root TLS 350 Dau of Testing/Servicing:9/18/2017 , c B. Inventory of Equipment Tested/Certified 3 Check the apEroeriate boxes to indicate specific equipment Inspected/serviced: Tank ID: Tank 1 Diesel Tank m: Tank 2 Diesel � ❑In-Tank Gauging Probe. Madel: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Madel: (1789438.301 ®Annular Space or Vault Sensor. MoleL 0789438.301 ®Frying Sump/Trench Sensor(s). Model: 07894380.208 ®Piping Sump/Trench Sensor(s), Model: 07894380-208 ®Fill Sump Sensor(s). Model: 07894380-208 ®Fill Sump Smsor(s). Model: 07894380-208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical lane Leak Detector. Madel: ®Electronic line leak Detector. Model: Veeder Root PLLD ❑Electronic Line Lcak Detector. Madel: ❑Tank Overfill/Ifigh-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ®Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank 3 Bioftsel Tank to: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model ®Annular Space or Vault Smsm. Model: 0789438-301 ❑Annular Space or Vault Sensor. Model: G ®Piping Sump/Trencb Sensor(s). Model: 07894380.208 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: 07894380.208 ❑Fill Sump Sensoria). Model: ❑Mechanical Line Lmk Detector. Mold: ❑Mechanical Line Irak Detector. Model: ❑Electrode line leak Detector. Modd: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Madel: ❑Tank Overfill/High-level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment R p type and model in Section E on Page 2). ,1 Dispenser ID: 1 Dispenser ID: 615 ®DispenserCmtainmentSensor(s), Model: 07894380.208 ®Dispenser Containment Scnsor(s). Madel: 07894380.208 ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chairds). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 112 Dispenser ID: 312 ®Dispenser Containment Sensor(s). Modd: 07894380.208 ®Dispenser Containment Sensor(s). Model: 07894380-208 ❑Shear Vatve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats)and Cbam(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 413 Dispenser ID: 4 & 7 ®DispmserContainment Smsot(s). Madel: 07894380.208 ®Dispenser Cuntam unt Sensor(s). Model: 07894380.208 ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Fkm(s)and Cham(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 manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this Information Is correct and a Plot Plan showing the layout of monitoring equl meut. For any equ�ipm, ent capable of generating such reports,l have also attached a copy of the report;(check all that apply): IN System set-up u Alarm history report Technician Name(print): Elmer Mortera Signature: �'L.--- Certification No.: A28170 License.No.: 396575 Testing Company Name: Balch Petroleum Phone No.:(408) 942-8686 Testing Company Address:930 Ames Avenue, Milpitas,CA 95035 Date of Testing/Servicing: 9/18/2017 Page 1 of 4 UN-036-1/4 www.unidocs.org Rev.01/17/08