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MAR-12-2012 14:11 Service Station Systems 408 938 8888 P.03 Monitoring System Equipment Certification For Use By All Jurisdictions Within The State of California Authorigi Cited: Chapter,6.7, Health and Sc7fety Code; Chapter 16. Division,3, 'Title 23, California Code of Re€17ilations This form must he used to document testing and servicing of monitoring equipment. A separate certificatis r nRort must he 91-pRared for each monitoring system control pancl by the technician who performs the work. A copy of this forth must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating l,1ST System within 30 days of test date. A. General Information Facility Name: Food 4 Less Bldg. No.: Site Address: 3408 Manthey Road -_ City: Stockton, CA Zip: 95206- Facility Contact Person: Manager Contact Phone No.: (209) 234-7869 Make/Model of Monitoring System: V/R TLS-350 Date ofTesting%Servicing: 2/13/12 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate Specific equipment inspectedAerviced: Tank ID:01-Re9u Tank ID' 02-Prom 18 in-Tank Gauging Probe. Model: VR 847390-111 ® In-Tank Gauging Probe. Model: VR 847390-111 0 Annular space or Vault Sensor. Model: VR 794390-420 gg Annular Space or Viitili Sensor, Model: VR 794190.420 Q Piping Sump\Trench Sensor(s). Model VR 794380-20e 19 Piping Sump\Trenclt Scnsor(s). Model: VR 784380-208 N Fill Sump Sensor(s). Model: VR 784380.208 ® Fill Sump Sensor(s). Madcl: VR 784380-208 ❑ Meehanicil Line Leak Detector. Model: ❑ Mechanical I,ine Look Delaclor. Model: 2 Electronic Lino Leak Detector, Model: VR caries 8484 ® Electronic Linc Leak Detector, Model: VR series 8484 ❑ Tank Overfill\High-Level Scnsor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section C on Page 2). ❑ Other(specify equipment type and model in Section F.on Page 2). Tank lD Tank lD• a In-Tank Gauging Probe, Model: ❑ in-Tank Gauging Probe. Model; ❑ Annular Space or Vault Sensor, Model; ❑ Annular Space or Vault Sensor. Model ❑ Piping Sump\'french Sensor(s). Model ❑ Piping Sump\Trench Sensor(s), Model: 0 Fill Sump Sensor(s). Model: ❑ hill Surnp Sensor(S). Model: [I Mechanical Line Leak Detector, Model ❑ Mechanical Line Leak Detector. Model: ❑ Flectronic Line Leak Detector. Model: ❑ Electronic Lino Leak Dei"ior, Model: ❑ Tank Overfill\High-Level Sensor. Model ❑ Tank Overfill\High-Lcvcl Sensor, Model: ❑ Other(specify equipment type and model in Section L on Page 2). ❑ Other(specify equipment type and model in Section F,on Page 2), Dispenser IQ01,02 . Dispenser ID: 03-04 Z Dispenser Containment Sensor(s). Model: VR 794180.208 9 Dispenser Containmcnt Sensor(s). Model: VR 794380-208 Q Shear Valve(S). ® Shear Valve(s). ❑ Dispenser Containment FlQmt(s);ind Chain(s). ❑ Dispenser Containment Float(.,;)and Chain(s), Dispenser ID: 05-06 Dispenser(11: 07-08 Cg Dispenser Containment Sensor(s). Model: vR 784380-208 ® Dispetl&Cr ContanmenL Sensor(S). Model: VR 794380.20a ® Shear Valve(s), Z Shear Valve(s). [] Dispenser Containment Float(s)and Chain(s). Cl Dispenser Containmcnt Ploit(3)and Chain(s). Dispenser lD: 09-10 Dispenser IQ, ® Diapenxer C.ontainrneat Sensor(s), Model vR 798880 2oa p Dispenser Containment Scnsor(s), Model; ® Shear Valve(s). ❑ Sher valve(s). ❑ DisnenacrContainntent Float(s)and Chain(s). rj Dispenser Containment Float(s)and Chain(s). *Ifthe facility contains more tanks or dispensers,copy This form. Include information for every Lank and dispenser at the facility C.Certification - 1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certiflcotion is information(e.g.manufactures'checklists)necessary to verify that this information Is correct find 8 Plot Plan showing the layout of monitoring equipment. For any equipmeol capable of generating such reports,f have also attached a copy of the; (chccka11 itatapply); ❑ System set-up d Alarm history report Technician Name(print),B an Lundien _ry Signature. Mfg.Ccrt-#.: B36094 ICC# 8001468-UT License, No.: 4851$4 Testing Company Name: Service Station Systems Phone No.: 408 971.2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 2/13/12