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Monitoring System Equipment certification For Use By All Jurisdictions Within The StatenfCali �! Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Div ision 3, Titl ons This form must be used to document testing and servicing of monitoring equipment. A separate certification o�st be prepared for each monitoring system control oanel by the technician who performs the work. A tP�ydo�tl�s €pfq� must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency raga ating UST system within 30 days of test date. ENVIRONMENTAL. A. General Information HEALTHOEPARiMENT Facility Bldg, No.: Site Address: 6425 N. Pacific Ave. City: Stockton, CA Zip: 95207 - Facility Contact Person: Manager Contact Phone No.: (209) 472-8600 Make/Model of Monitoring System: V/R TLS -350 Date of Testing/Servicing: 1121114 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced: Tank ID: 01-Regu Tank ID' 02 -Prem ® In - Tank Gauging Probe. Model: VR 647390409 Cl In - Tank Gauging Probe. Model. VR 647390.109 ® Annular Space or Vault Sensor. Model: VR 794390160 10 Annular Space or Vault Sensor. Model: VR 794]90460 ® Piping Sump \Trench Senom(s) Model: VR 794380.206 0 Piping Sump Trench Sensor (s). Model: VR 79380-208 ® Fill Sump Sensor (s). Model: VR 794360-236 0 Fill Sump Sensor (s). Model: VR 794360-206 ❑ Mechanical line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model! ® Electronic Line Leak Detector. Model; VR sena, 6484 ® Electronic Line Leak Detector. Model: VR series 8484 ❑ 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 F! on Page 2). Tank 11): 03 -Diesel Tank ID: 00 In - Tank Gauging Probe. Model: Va 647380-309 ❑ In - Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: VR794390-460 ❑ Annular Space or Vault Sensor. Model. a Piping Sump\ Trench Sensor (s) Model: VR 794380-208 ❑ Piping Sump\ Trench Sensor (s). Model: 0 Fill Sump Sensor (s). Model: VR 794360-208 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Linc Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR senna 6434 ❑ 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 ID: 03-04 ® Dispenser Containment Sensor (s). Model VR 794360-236 M Dispenser Containment Sensor (s), Model: VR 79383208 ® Shear Valve (s). 0 Shear valve (s). ❑ Dispenser Containment Floor (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID- 06.08 Dispenser ID' 07-08 ® Dispenser Containment Sensor (s). Model: VR 794360-206 0 Dispenser Containment Sensor (s). Model: VR 78380208 ® Shear Valve (s). ® Shear valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 08-10 Dispenser ® ID: 11.12 Dispenser Containment Sensor (s). Model: VR 794380,208 ® Dispenser Containment Sensor (s). Model: VR78380.206 ® Shear Valve (s). ® Shear Valve W. ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment HOaI(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 inapected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufnclures' checklist, ) neee,,., to verify that this information is correct and a Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have also attached a copy of the; ( rheeAatt thatapply): Technician Name (print): Kris Bell Mfg, Cert.#.: 833709 ICC# 5297793 -UT System set-up ❑ Alarm��hifsttoorryy report Cienature. �-"""' 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: 1/21114