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MONITORING SYSTEM CERTIFICATION For Use ByAll Jurisdictions Within the State ofC �` I N� if Authority Cited: Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, T `Lh or '�, 'ode of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or re ort nmst be re ared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provid@@o(the tanld );em owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information ENVIRONMENTAL HEALTH FacilityName: 953 Tracy Fedex Ground pEPAR1T Site Address: 5655 Hood Way City: Tracy Zip: 95377 Facility Contact Person: Jose Jimenez Contact Phone No.: (209) 830-5254 Make/Model of Monitoring System:Veeder Root TLS 350 Date of Testing/Servicing: 9/18/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui meut inspected/serviced: Tank ED: Tank Diesel Tank ID: Tank 2 Diesel ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 0789438-301 ®Annular Space or Vault Sensor. Model: 0789438-301 N Piping Sump/Trench Sensor(s). Model: 07894380-208 ®Piping Sump/Trench Sensor(s). Model: 07894380-208 N Fill Sump Sensor(s). Model: 07894380-208 ®Fill Sump Sensor(s). Model: 07894380-208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector, Model: N Electronic Line Leak Detector. Model: Vender Root PLLD ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: N Other(specify equipment type and model in Section E on Page 2). N Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank 3 BioDiesel Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 0789438-301 ❑Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 07894380-208 ❑Piping Sump/Trench Sensor(s). Model: N Fill Sump Sensor(s). Model: 07894380-208 ❑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: 1 Dispenser ID: 6/5 N Dispenser Containment Sensor(s). Model: 07894380-208 N Dispenser Containment Sensor(s). Model: 07894380-208 ❑ ShearValve(s). ❑ ShearValve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 1/2 Dispenser ID: 3/2 N Dispenser Containment Sensor(s). Model: 07894380-208 N Dispenser Containment Sensor(s). Model: 07894380-208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s) DispenserID: 4/3 Dispenser ID: 4 & 7 N Dispenser Containment Sensor(s). Model: 07894380-208 N Dispenser Containment Sensor(s), Model: 07894380-208 ❑ ShearValve(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 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 equipment. For any equipment capable of generating such reports,I have also attached a copy of the report; (check al/that apply): ® System set-up ❑Alarm history report Technician Name(print): Elmer Mortera Signature: 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 w .unidocs.org Rev.01/17/08