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Monitoring System Equipment Certification For Use By All 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 Bldg. 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: 6/20/12 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 M7390-109 ® In- Tank Gauging Probe. Model: VR847390409 ® Annular Space or Vault Sensor. Model: vR 79090460 ® Annular Space or Vault Sensor. Model: va794390480 0 Piping Sump \ Trench Sensor (s). Model: vR 79080-008 ® Piping Sump \ Trench Sensor (s). Model: V!1794380-208 III Fill Sump Sensor (a). Model: va 794380-2ae CO Fill Sump Sensor (s). Model: VR waren-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR renes UN N Electronic Line Leak Detector, Model: VR Santa. 804 ❑ 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 II); 03 -Diesel Tank ID: M In -Tank Gauging Probe, Model: VR U7390,1 Do ❑ In - Tank Gauging Probe. Model: I& Annular Space or Vault Sensor. Model: VR 79090460 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump \ Trench Sensor (s). Model: VR 794380-20 ❑ Piping Sump \ Trench Sensor (s). Model: ® Fill Sump Sensor (s). Model: VR 794380-008 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Cl Electronic Line Leak Detector. Model: VR Serie. Bda4 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Levet 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 79080.208 N Dispenser Containment Sensor (s). Model: vR 764380-208 ® Shear Valve (s). 0 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 05.06 Dispenser 11)• 07-06 ® Dispenser Containment Sencor(s). Model: VR 794380.209 ® Dispenser Containment Sensor (s). Model: vR 794380.208 ® Shear Valve (s). N Shear Valve (s). ❑ Dispenser Containment Float (a) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 09.10 Dispenser .. 11-12 ® Dispenser Containment Sensor (a). Model: VR 794380-208 E Dispenser Containment Sensor (a), Model: VR 794380.208 ® Shear Valve (s). M 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; (check all that apply); ❑ System set-up ❑ Alarm history report Technician Name (pont): Myk® Briggs Signature:^7 /' Mfg. Cert.#.: 838235 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: 6/20112