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RECEIVED Monitoring System Equipment CertificatioYN 2 7 2017 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 certifi EtNVIR�p TbL HEALTH prepared for each monitoring system control panel by the technician who performs the work. A copy of this for - Ae�'WaT 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: 12/29/16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01-Regu Tank ID• 02-Prem 0 In-Tank Gauging Probe. Model: VR 846390-111 CC In-Tank Gauging Probe. Model: VR 846390-111 ® Annular Space or Vault Sensor. Model: VR79439CA6o ® Annular Space or Vault Sensor. Model: VR 79439046a 0 Piping Sump\Trench Sensor(s). Model:—VR 794380-20e DO Piping Sump\Trench Sensor(s). Model: VR 794360-208 ® Fill Sump Sensor(s). Model: VR 784360-208 ® Fill Sump Sensor(s). Model: VR 794380.208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR Series 8484 ® Electronic Line Leak Detector. Model: VR series edea ® Tank Overfill\High-Level Sensor. Model: VR 790091.001 ® 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 F.on Page 2)- ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser IDs 01-02 Dispenser ID: 03-04 ® Dispenser Containment Sensor(s). Model: VR 794380-20e I@ Dispenser Containment Sensor(s). Model: VR 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-06 LDispenser ID: 07-08 ® Dispenser Containment Sensor(s). Model: vR 794380-208 er Containment Sensor(s). Model: VR 784380-zoa Shear Valve(s). alve(s). Dispenser Containment Float(s)and Chain(s). er Containment Float(s)and Chain(s). Dispenser ID: 09-10 Dispenser IDS ® Dispenser Containment Sensor(s). Model: VR 794380-208 ❑ 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- f 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; (cheek all that apply): ® System set-up ® Alarm history report Technician Name(print): Brian McPheely Signature:_ Mfg.Cert.#.: B36745 ICC# 8394903-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/Servicing: 12/29/16