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EZ PLAINT PA 0I� 03/14f2fl16 09: 36 9163712546 - I.TOPING SYSTEM CERTIFICATION APR 06 2016 01� For Use By All Jurisdicttons within the Stare of ColVor"ia Aulhoriry Cited,Chapter 6.7,Health and Softly CYdB!Chapter 16, DiviBion 3,T(tle 23,Caltfnrnta Cvde of Fegularinns cation rt mus re Bred e c mo l erforrry the work, A.copy of this form must be provided to the tank system 0%VnC'rfoPerator. The o�vnerroperator This form must be used to document Besting and servicing of manitarpy equipment, A z evstem connol canal by the technician who p must submit a copy of this{arm to the or agency regulating UST systems within 30 days of test ate. A. General Information County: .5 AQ�a�! Facility Name: COUNTRY MARKET PLACE City: gT )CKTON R WAY Contact phone 2Qg-941-2222 Site Address: 1789 W CHARTE Facility Contact person: BARD G)<LL Date o£Testing/Servicing: 31i01� 2u_ Make/Model of Monitoring System: TLS350 B. Inventory of Egnipment Tested/Certified Tank 11); 91 Model 141AG Tank ID: 187 Model: fv1pG M to-Tank Gauging Probe. M In-Tank Gauging Probe. ®Annular Space or Vault Sensor, Model: 420 ®Annular Space or Vault Sensor. Model: 420 ®p;ping 5urnp 1 Trench Sumor(s). Model: 208 IT Sensor(s). Model• 208 Model: ®.piping Sump ❑Fill Sump Sensar(s). Model: ❑ IV Fill Sump Sensw(s). ®Mechanical Line Leak lDetector. Madel: FX Mechanical Line Leak Detector, Model: L021►Dp ❑ Electronic Line Leak Detector. Model ❑ Ejectronic Line Leak Detector. Model: ®Tank Overfill/High-Leve]Sensor Model: MAG ®Tank Overfill I High-Level Sensor. Model: MAG ❑Other(specify equipment type and model in SeGt,on E on Page 2) Q outer(specify equipment type and model in Section E on Page 2). Tank 10- Tank ID' Model: Model'. ❑In-Tank Gauging Probe. ❑In-Tank Gauging Probe. ❑At,nular Space or Vault Sensor. Model- ❑ Annular Space or Vault Sensor. Model: E]piping Sump/Trench Sensor{s). Model; ❑Piping Sump/Trench Sensor(s). Model: model Model. El Fill Sump Sensor(s), ❑Pill Sump Sensods) ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Modet: ❑Electronic line Leak Detector. Model. ❑ Electronic Lille Leak Detector. Model: ❑-rank Overfill f High-Level Sensor. Modcl. }Yank overfill 1 High-Level Sensor. Model: Z ❑Other(specify equipment type and model in Section E,n Page 2]. [�Other(specify equipment type and model in section E on Page ). Dispenser ID: 314 Dispenser IID; 11L ( Dispenser Containment$cnsar(s). Madel. 322 ®Dispenser Containment Sensor(s). Model: 322 ®Sbear Valve(s) and Chain(s]. ❑Dispenser Containment Floats)and Cha TIM- ❑ Dispenser Containment Float(s) Dispenser lD: 7/6 Dispenser iD: 516 ®Dispenser Containment Sensor(s). Model: 322 ( Dispenser Containment Sensor(s). Model: 322 Shear Valve(s). ®Shear Valve(s). n Dispenscr Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: 11/12 Dispenser 1i?: 9/lD ®Dispenser Containment Sensor(s). Model: 3z2 ®Dispenser Containment Sensar(s). Model: 322 ®Shear Valve(s), M Shear Valve(s). [j Dispenser Containment Float(s)and Chain(s). ❑Dispmser Containment Float(s)and Chain(s). Check the appropriate boxes to indicate specific equipment irtspectedlscrviced: pec C. Certification - I certifyhAt thetoquis Certifith the cation entifiiPfnentis edinfortntaton (e.gnm nufa tuprersedcheckliss)tnecessaryato vernce ify that manufacturers' guidelines A this information is correct and a Ptah showing the 19yout of monitoring equipment.System Fol set-uquipmentAlarm his capable f ry re ttnt such reports,I have also attached a copy of the report, (check all that gpply): ® Tint ALEXANDER Tecklztician Name(print): ANDER TATE SignatuLicense No._ 331.59 Ceztificatitm 542662 Testing Company Name: B. Z.Service Station iVlaintenance Phone No.: (976 3'11.2380 Site 1041 Triangle Court West Sacrattletlto CA 95645 Date of Testing/Servicing: 3l10l2015 141on.itoring Certification Test Report 1 of 4