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MONITORING SYSTEM CERTIFICATIO ':: i For Use By All Jurisdictions Within the State of California RR Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Re�5t .2 3 1V C U 2018 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for.each-;cALTH monitoring system control panel by the technician who performs the work. A copy of this form 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 systems within 30 days of test date. A. General Information Facility Name: YRC #813 Site Address: 1535 E. Pescadero Avenue Facility Contact Person: Ruben Make/Model of Monitoring System: Veeder-Root TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eouiument inspected/serviced: City: Bldg. No.: Tracy Zip; 95304 Contact Phone No.: (913) 344-3644 Date of Testing/Servicing: 02/01/2018 Tank ID: Waste oil 4000 gal Tank ID: Waste oil gate 1000 gal N In -Tank Gauging Probe. Model: 84739o107 W In -Tank Gauging Probe. Model: 841390-107 ❑� Annular Space or Vault Sensor. Model: 3os K Annular Space or Vault Sensor. Model: 303 ❑� Piping Sump / Trench Sensor(s). Model: 1943e0-208 X Piping Sump / Trench Sensor(s). Model: 794380-209 ❑ Fill Sump Sensar(s). Model: ❑ Fill Sump Sensoria). 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). Tank ID: Anti -Freeze 6000 gal Tank ID: Gear oil 6000 gal N In -Tank Gauging Probe, Model: 841390-107 In -Tank Gauging Probe. Model: 841390-107 ❑� Annular Space or Vault Sensor. Model: 303 ❑a Annular Space or Vault Sensor. Model: 303 ❑Q Piping Sump / Trench Sensor(s). Model: 7943e0-208 Piping Sump / Trench Sensor(s). Model: 79438a208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensoria). 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: Dispenser ID: ❑ 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ 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 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 all that apply): X System set-up Alarm history report Technician Name (print): Aaron Perrigo Signature: LOW— Certification No.: 847853 License. No.: 804904 Testing Company Name: Confidence UST Services, Inc. Phone No.: (800) 339-9930 Site Address: 1535 E. Pescadero Avenue Tracy, CA Date of Testing/Servicing: 02101/2018 Page 1 of 3