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RECEIVED FEB 17 2017 Monitoring System Equipment Certification For Use By All Jurisdictions Within The State of California ENVIRONMENTAL Authority Cited. Chapter 6.7, Health and Safely Cade; Chapter 16, Division 3, Title 23, California Cade 0. lJT IQEPARTMENT This form must be used to document testing and servicing of monitoring equipment. A separate certification or reoort must be orenared 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 system within 30 days of test date. A. General Information Facility Bldg. Site Address: 6425 N. Pacific Ave. City: Stockton, CA Zip: 95207 - Facility Contact Person: Caroline Contact Phone No.: (209)472.8600 Make/Model of Monitoring System: VR TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 1119/17 Tank III: 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 (a), Model: ❑ Fill Sump Sensor (a), Model: ❑ Mechanical Line Lank Detector. Model: 0 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ lank 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 I11, 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 (a). Model: ❑ Piping Sump\ Trench Sensor (S). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (a). 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 1% 13-74 Dispenser iD- 15.16 0 Dispenser Containment Sensor (a), Model: VR796380-208 ® Dispenser Containment Sensor (a). Model: VR 794380-20a 11 Shear Valve (s). ® Shear Valve (s), ❑ Dispenser Containment Float (s) and Chain (s), ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: Dispenser LD: ❑ Dispenser Containment Sensor (a), Model: ❑ Dispenser Containment Sensor(a). Model: ❑ ShearValve (s). ❑ Shear Valve (s) ❑ Dispenser Containment Float (a) and Chain (s), ❑ Dispenser Containment Float (s) and Chain (s). Dispenser 1D' Dispenser ID; ❑ Dispenser Containment Sensor (a). Model: ❑ Dispenser Containment Sensor (a). 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 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): 2 System set-up I 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: 880 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 1/19/17