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RECEIVE® Monitoring System Equipment Certifies i� For Use BY All Jurisdictions Within The State of California �A" 2 201 a 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 ctgN�&J Qr M: -�EAJH prepared for each monitoring system control panel by the technician who performs the work. A copy of thi9WrrR�&[MW,4Xded to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name: Gas 4 Less Bldg.No.: Site Address: 3434 Manthey Road City: Stockton,CA Zip: 95206- Facility Contact Person: Jesus Contact Phone No.: (209) 234-7869 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 12/13/17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank I])•01-Regu Tank ID• 02-Prem M In-Tank Gauging Probe. Model. VR 846390.111 M In-Tank Gauging Probe. Model: VR 846390-111 M Annular Space or Vault Sensor. Model: VR 794390.460 M Annular Space or Vault Sensor. Model: VR 794390-460 M Piping Sump\Trench Sensor(s). Model; VR 794360.206 M Piping Sump\Trench Sensor(s). Model: VR 794380.208 M Fill Sump Sensor(s). Model: VR 794380.208 M Fill Sump Sensor(s). Model: VR 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: M Electronic Line Leak Detector. Model: VR Series 8464 M Electronic Line Leak Detector. Model: VR series 8484 ® Tank Overfill\High-Level Sensor. Model; VR 790091-001 M Tank Overfill\High-Level Sensor. Model: VR 790091-001 ❑ 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 Tank 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• 01-02 Dispenser We 03-04 M Dispenser Containment Sensor(s). Model: VR 794380-206 M Dispenser Containment Sensor(s). Model: VR 794380-208 M Shear Valve(s). M Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• 05-06 Dispenser ID1 07-08 M Dispenser Containment Sensor(s). Model: VR 794360.206 M Dispenser Containment Sensor(s). Model: VR 794380-208 ® Shear Valve(s). M Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 1D• 09-10 Dispenser ID M Dispenser Containment Sensor(s). Model: VR 794360-208 ❑ Dispenser Containment Sensor(s). Model: M 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 manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'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; (check all that apply): ® System set-up ® Alarm history Technician Name(print): Kris Bell Signature: Mfg.Cert.#.: B33709 ICC# 5297793-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Seryicing: 12113/17