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MONITORING SYSTEM CERTIFICATION F�;3 ��1R 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 reoort must 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/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 FacilityName: YRC #813 Site Address: 1535 E. Pescadero Avenue Facility Contact Person: Ruben Make/Model of Monitoring System: Veeder-Root TLS -300 B. Inventory of Equipment Tested/Certified Check the annrooriate boxes to indicate specific eouinment inspected/serviced: Bldg. No.: City: Tracy Zip: 95304 _ Contact Phone No.: (913) 344-3644 Date of Testing/Servicing: 02/01/2018 Tank ID: Soap 1000 gal. Tank ID: ❑O In -Tank Gauging Probe. Model: 847390-10e ❑ In -Tank Gauging Probe. Model: K Annular Space or Vault Sensor. Model: 7s43se409 ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: 7W80-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill 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 Overfill / High -Level Sensor. Model ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specity equipment type and model in Section E on Page 2). Tank ID: "fank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model ❑ Fill 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 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 Sensm(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) L] Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser to: Dispenser ID: ❑ Dispenser Containment Seasons). 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): ❑ System set-up Alarm history report A Technician Name (print): Aaron Perrigo _ " Signature: Lew— Certification No.: 647853 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: 02/01/2018 Page 1 of 3