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Monitoring System Equipment Certification For Use ByA11 Jurisdictions Within The Slate 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 certification or report must be prepared 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 Name_ 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 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Inspected/serviced: Date of Testing/Servicing: 10/17/12 Ton 11): TankM- • 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). Tank D?: Tank M: ❑ 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 (a). Model: ❑ Fill Sump Sensor (a). Model: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leek Detector. Model: ❑ Mechanics] 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). Disppenser M. 13.14 Dispenser ID• 15.16 00 ]Sispepser Containment Sensor (s). Model: VR 7943813-20e ® Dispenser Containment Sensor (s). Madel: VR 794380.208 ® Shear Valve (s). ® ShearValve (s), ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID:Disppenser ID: ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensar (s). Model: [I Sheer Valve (s). ❑ ShearValve (s). [I Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (a) and Chain (s). Dispenser ID: CI Dispenser Containment Sensor (s). Model: Dispenser ID: ❑ Dispenser Contaimnent Sensor (s). Model: ❑ Shear Valve(s). ❑ ShearValve(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 Cc runes thin 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): ® Systemset-up ® Alarm history report Technician Name (print): Myke Briggs Signature: Mfg. Cert.#.: B38235 ICC# 8033115 -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: 10117/12